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SAN JOAQUIN COUNTY JUL 3 0 2009 <br /> { ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> I" <br /> 600 East Main Street, Stockton, CA 95202-302bNVIRONMENT HEUT-hGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sacla6 ERVICES UNIT IV <br /> W I� r3 WELL PERMIT APPLICATION C v <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 /> 6632 Pacific Avenue Benjamin Holt Drive Stockton 95207 Assessor's 08126020 <br /> Well Location Cross Street City Zip Parcel# <br /> Property City of Stockton 425 N.EI Dorado Street Stockton 95202 (209)937-8121 <br /> Owner Address City Zip Phone# <br /> C-57 Contractor Cascade Drilling, Inc Address 3632 Omec Circle City Rancho Cordova Lic# 932633 Phone (916) 638-1169 <br /> Consultant/Sub Cntr Holguin Fahan 8 Associates Address 5627 Stroneridge Drive,Suite 300 City Pleasanton Lic#N/A Phone (805)641-4091 <br /> GIS Coordinates:X 32.010 -y Township T2N Range R6E Section S21 <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-ANGER, THER-) DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# d OVER-BORE DIAMETER 8"for 2"wells,10"for 4"wells <br /> [IWELL# PRESSURE GROUT <br /> ❑`OTHER I ifvvv GROUT SPECIFICATIONS <br /> COMMENTS: Total of 3 off-site wells in 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 ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> 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 hav prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, a Icable California Laws. <br /> Signed Title/Company OV . I`�/�ror•/C <br /> a*6AAe_1>✓1 I I(I� , jnc, <br /> Print Name �O�3G1X�(�( 1 I n Date 0-7 ( o/�1 <br /> DEPARTMENT USE ONLY <br /> Z . 5J� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: &��/ <br /> WORK PLAN DATED: 1,7 Q <br /> APPLICATION ACCEPTED BY I ( -U AREA (� <br /> GROUT INSPECTION BY FINAL INS ECTI DA 1 <br /> DESTRUCTION INSPECTION BY DATE <br /> if <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> Z ?� -31-09 R# <br /> C-57 WC 440AIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENTDOC <br /> EHD 29-01 11/5107(WEB) / ,//s WELL PERMIT APP <br /> V" 1�r 32- <br />