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1 <br /> —San Joaquin County <br /> ara r -�V j Environmental Health Department �� (^fin SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 �L�11 M/ <br /> I� `I�GATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/chdMAR UNIT IV <br /> Well Permit Application ENVIRIVi j © ZQOS <br /> r NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDpERMjTTr�Ef-p HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appli/ tn1d�(ag in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 716 North Oro Street Fremont/Oro Stockton 95215 Assessors <br /> WELL Location Cross Street City Zip Parcel# 143-33-03 <br /> PROPERTY <br /> OwnerJesus/Maricella Alvarezgddress 1422 Jupiter-Ct' Milpitas Zip 95035 Phone# 408-263-6014 <br /> C-57 Contractor Gregg Drilling pG �dy Martinez Zip 94553 Uc#656407Phone#925-313-5800 <br /> r <br /> Consultant/Sub Cnir V <br /> A.G.E. �) ) _City Lic# Phone#f .,. Stockton 680227 209-4.67-1006 <br /> _ <br /> GIS Coordinates:X ,Y n /,/)��r� Range- Section <br /> WORK TO BE PERFORMED: Luo✓ •�' ', , <br /> ANEW WELL/BORING (CPT GEOI it )THER-) p DESTRUCTION (choose type below) <br /> SOIL BORING# - — -�-I .� 0 OVER-BORE. DIAMETER <br /> 4 WELL# MW-5 a B PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS. Reference Work Plan,. dated 05 December 2007 & EHD-approval letter dated 18 January 2008 <br /> ' TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )$MONITORING )THOLLOW STEM ' • DIA.OF BOREHOLE 8" a MULTIPLE CASINGS 0 MULTI-LEVEL. WELL CASING DIA: 2" <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ached. 40 TYPE OF CASING: 0 STEEL >OPVC 0 OTHER: <br /> ` 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 40'- TREMIE TYPE TO BE USED: U AUGERS 0 HOSE <br /> + n AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Type II <br /> 0 OTHER: p OTHER APPROX.BORING DEPTH 65, 48OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> - CONDUCTOR CASING PROPOSED NO (if YES,list specifications in comment section) <br /> COMMENTS: Reference Work Plan dated 12/05/07 & RHD-approval letter dated 01/18/08 <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 Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x-11 'lR. Title/Company Project Geologist/A.G.E. <br /> Print Name Timoth J. Cuellar Date 03-05-08 <br /> DEPARTMENT USE ONLY <br /> I SITE MAP IN UNIT IV FILE, ADDRESS: <br /> 1, WORK PLAN DATED: - <br /> !+l Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> 1 ACCOUNTING ONLY: AID# - FAC# <br /> I <br /> I PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11/2007 - <br />