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�oPq�•N. �o `,San Joaquin County <br /> z Environmental Health Department JUN 10 2011 SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 ITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.bNMENT HEAL <br /> �<<FOKN`P • PERMIT/SERVICES UNIT IV <br /> Well Permit Application <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 /> 2969 Loomis Road Hwy 99 Stockton 95252 Assessors 179 11-024 <br /> WELL Location Cross Street City Zip Parcel# <br /> PROPERTY Margaret Marci 707 465-6015 <br /> Owner g Address 20 Mobile Lane City Cresent City Zip 95531 Phone#( ) <br /> V&W Drilling & 3806 Duck Creek Drive Stockton 95215 720904 (209) 469-7700 <br /> C-57 Contractor CPT, Inc. Address104 Constitution DriveCityMenlo ParkZip94025 Lic#884827 Phone# (650 <br /> __4 00 <br /> Consultant/Sub Cntr Geological Technics Inc. Address 1172 Kansas Avenue City Modesto Lic# NSA Phone# (209)522-4119 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> pxNEW WELL/BORING (CPT,GEOPROBE,WYYDROPUNCH;HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> [t SOIL BORING# 4 CPT & 4 Adjacent Boreholes (GW-1 thru GW-4) a OVER-BORE. DIAMETER <br /> a WELL# []PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS:_ See Work Plan dated February 28 2011 and County Approval letter dated June 1 2011 C 1 o y <br /> 1L FE <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING E[HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS o MULTI-LEVEL WELL CASING DIA: <br /> o EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS []HOSE <br /> a AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes 11 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING(8) a HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: 0 OTHER APPROX.BORING DEPTH o BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: See Work Plan date February 28 2011 and County Approval letter dated June 1 2011 <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 Ordinnces, e� gulations, and all applicable California State Laws. <br /> Signed x_ /� Title/CompanyC--I_ 1AP i UV lj Cct ( -Tee h1NI'6'i ;� C, - <br /> Print Name P)Gi t(r)0IC( 3, Date �-'J-)ilk <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 226,17 L.o omi s —h o a d <br /> WORK PLAN DATED`: / Ee- r '9 r- s 2 8 a0 )1 <br /> Application Accepted By V i0-i--r i M C-Ca rig,e 1v—Date Issued 6 — t o —d Area .- <br /> Grout Inspection By V1ad-,-)g L �- Date G 2�—�/ Final Inspection By V i An."k, Date 6—.78 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 360S " I P <br /> ' -r- as 026070 `ii'`Yl1 6-to-11 SR# dl) 2 2 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 ow 3 /I-/ <br /> 6/22/04 "t'�! <br />