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SAN JOAQUIN COUNTY <br /> JUL 3 0 2009 <br /> ENVIRONMENTAL HEALTH DEPARTMENT SI <br /> 1 600 East Main Street, Stockton, CA 95202-302bNVIRONMENT li <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.siaERVI T <br /> 1� C33 Q WELL PERMIT APPLICATION g <br /> &;� <br /> o1 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 /> 6632 Pacific Avenue Benjamin Holt Drive Stockton 95207 Assessor's 08126020 <br /> Well Location Cross Street City tp Parcel# <br /> Property Ci of Stockton 425 N.EI Dorado Street Stockton 95202 <br /> Owner City Address City Zip Phone# (209)937-8121 <br /> C-57 Contractor Cascade Drilling,Inc Address 3632 Omec Circle City Rancho Cordova LIC# 932633 Phone (916)638-1169 <br /> Consultant/Sub Cntr Holi"M Fahan a Assouates Address 5627 Stroneridge Drive,Suite 300 city Pleasanton Lic#N/A Phone (805)641-4091 <br /> GIS Coordinates:X R.-Oto - .y •"12E Township T2N Range RISE Section S21 <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-ANGER, THER-) I DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# _ ✓ OVER-BORE DIAMETER 8"for 2"wells,lo'for 4'wells <br /> ❑WELL# 1 PRESSURE GROUT <br /> ❑-OTHER GROUT SPECIFICATIONS <br /> COMMENTS: Total of 3 off-site wells i city of Stockton ROW ill be destroyed. See attached boring logs for construction details. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH <br /> CONDUCTOR CASING PROPOSED ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: — (i1 YES.list specifications in cornntent section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I ha prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and I <br /> Regulations, cable California Laws. <br /> Signed .0 Title/Company OV"t✓5. IV IAr.�C�riIGrJ Pi�YI I/tQ)i fY?(i'r <br /> Pri it Name _ _ h�_� a��j ��(,�� (� Date 0- 1 ?-50 (Oq <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: a&tf 1z Q <br /> APPLICATION ACCEPTED BY DATE ISSUE ` 00 AREA WTA_ <br /> GROUT INSPECTION BY FINAL INSSr CT1% BY DATE <br /> �a',�/ <br /> DESTRUCTION INSPECTION BY DAA —?I <br /> r <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK <br /> # �/1/ RECV'D BY DATE�yp 9 PERMIT/SERVICE# INVOICE <br /> AA <br /> • V 2 �✓��( <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROAQHMENT DOC <br /> EHD 21)-01 11/5/07(WEB) - WELL PERMIT APP <br /> X1102. <br />