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�oQa 'N,co pan Joaquin County <br /> Environmental Health Department �E SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 (f�j CLg TION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd IV <br /> ` JUL 10 <br /> Well Permit Application ENVI p/I f2 1� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PER I��t��`���LLIVTNEj(��,`/� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This apli��ti' ompliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> oP w w��^^ �Oti 7T- Port Road 2 Stockton 95201 <br /> Assessors145-03-009 <br /> WELL Location Cross Street 2City Zip Parcel# <br /> PROPERTY <br /> Owner Port of Stockton Address2201 W. Washington St City Stockton Zip 95240 Phone#(209) 946-0246 <br /> C-57 Contractor Penec ore Drilling Address1238 Alice Street City Woodland Zip95776 Lic# 906899Phone#(530) 661-3600 <br /> Consultant/Sub Cntr WGR Southwest Address 315 W. Pine St. City Lodi Lic# Phone# (209) 334-5363 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> $SOIL BORING# 10 OVER-BORE. DIAMETER <br /> 0 WELL# Q PRESSURE GROUT <br /> Il*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE-2" MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: _ <br /> Q EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC G OTHER: <br /> a VAPOR MUD ROTARY DEPTH OF GROUT SEAL <15' TREMIE TYPE TO BE USED: a AUGERS V HOSE <br /> a AIR SPARGE/OZONE d PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes [jNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING til HAND AUGER GROUT SPECIFICATIONS Portland Neat Cement <br /> 0 OTHER: a OTHER APPROX.BORING DEPTH <15' a BOLTED TRAFFIC BOX or O STOVE PIPE <br /> ? 0,� CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or 'nances, Rules and Regul ions, and all applicable California State Laws. <br /> Signed / 22 Title/Company Compliance Specialist / WGR Southwest. Inc. <br /> Print Name''James Neal Date 7/12/2010 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:dt[ '�/ n <br /> WORK PLAN DATED: 10 <br /> Application Accepted B // e�4([A�11� Date Issued ( L10 <br /> Area <br /> Grout Inspection By��Lde Date � l0 10 Final Inspection By Date IP !b <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: Sim <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> eq <br /> Dr �`r �'�- l 9/ Z� �� '1 �� �v sR# 660 ? <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 3 <br />