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>'_� '' San Joaquin County �� ���jl�\//; I �_ <br /> Environmental Health Department SITE <br /> :K 600 East Main Street, Stockton, CA 95202-3029 <br /> JUL TIibATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> c�r+ 9„r :% NIT IV <br /> ENV1R0NK4tl�ii iTITH <br /> — Well Permit Application FFRP,91T,a 00,; <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 375 W.Hazelton Ave. xa=auoa a scocc Assessors <br /> WELL Location Cross Street City Stockton Zip 95207 Parcel# <br /> PROPERTY 375 W. Hazelton Stockton <br /> Owner Eger Properties Address CityZip 95207 Phone# 209-943-7777 <br /> C-57COntmctor Gregg Drilling Address 950 Howe Rd. CityMartinez Zip 94553 Lic#485165 Phone# 925-313-5800 <br /> Consultant/Sub Cntr A.G.E Address 837 Shaw Rd. City Stockton Uc# 680227 Phone# 209-467-1006 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/BORING (CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') D DESTRUCTION (choose type below) <br /> 0�80I1­BORING# CPT-1 through CPT-5 D OVER-BORE. DIAMETER <br /> D WELL# D PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: See EHD-approved work plan dated 14 April 2008 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE 2 D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA:na <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS ria TYPE OF CASING: D STEEL D PVC D OTHER: as <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL 100' TREMIE TYPE TO BE USED: GAUGERS D HOSE <br /> D AIR SPARGE/OZONE &PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Bales D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> }SOIL BORING D HAND AUGER GROUT SPECIFICATIONS Portland Type 11 <br /> D OTHER:_0 OTHER APPROX.BORING DEPTH 100 D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED na (if YES,list specifications in comment section) <br /> COMMENTS: See EHD-approval letter dated 03 July 2008-cci-r <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 -Ii,Wwt"M ,,J.. s-,� ` Title/Company Project Manager/A.G.E. <br /> Print Name Thy J. Cuellar Date 07/15/08 <br /> DEPARTMENT.. 1USE ONLY <br /> SITE MAP IN UNIT IV FIL ,ADDRESS: �75� W • Yd [!vim Q - L°G�c L <br /> WORK PLAN DATED: 140-Lt 2,007 <br /> Application Accepted B a / IDate Issued 71 Lee Ared?7 <br /> Grout Inspection By —Date- Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: L.0 - Cwt <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3soi 85 �'� <br /> d--21y8 6Je- -7 v SR# oa 14�611 <br /> C-57_ WC=WAIVER_ C-57 Letter of A'.,thorization to sign 4rmit Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11!2007 <br /> ^�.� <br />