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N, N aICOUNTY OUNTY `" WI ..� A, SA1 ENVIRONMENTAL HEALTH DEPARTMENT JUL 3 0 2009 SITE i # 600 East Main Street, Stockton, CA 95202-3029 MITIGATION Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.4W.i36 NT HEAI TUNIT IV PERMIT/SERVIG ES _ WELL PERMIT APPLICATION ` NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED wA y- 7 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 Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. 6633 Pacific Avenue Benjamin Holt Drive Assessor's Well Location Cross Street 1 Cid, Stockton Zip 95207 parcel# 09741048 Property Lincoln Center Trust PO Box 7611 San Francisco 94120 (510)237-1782 Owner Address City Zip Phone# C-57 Contractor Cascade Drilling, Inc Address 3632 Omec Circle City Rancho Cordova Lic# 932633 phone (916) 638-1169 ConsultanUSub Cntr Holguin Fahan&Associates Address 5627 Stroneridge Drive,Suite 300 City Pleasanton Lic#N/A Phone (805)641-4091 GIS Coordinates:X 3�. u 'y �.�.3Z( ,Township T2N Range RISE Section S21 WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(CHOOSE TYPE BELOW) [I SOIL BORING# /'� ��l//�QOVER-BORE DIAMETER S"for 2"wells,10"for 4"w It E] s WELL# / PRESSURE GROUT [:1*OTHER — GROUT SPECIFICATIONS 1 M(I- /117- COMMENTS:— TYPE COMMENTS:_TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SP6QIFIQATIONS ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLEQf/0 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE Q /I CONDUCTOR CASING PROPOSED ,f YES,list specification in comment section COMMENTS:Trr� — f 7 d� CSS f-r/ �.i. t 7�7 zr 72 6�T z�� / rt-- NOTE: n NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and Regulations,Wd all applicable California Laws. /� T Signed Title/Company Dom• M�r. I C�GC�i d VV�t'I Y7 C, Print Name 162h ' 'CD Date 0~7 1 %0 ' C-29 DEPARTMENT USE ONLY z? S77-- _ SITE MAP IN UNIT IV FILE,ADDRESS: �fL/ kw WORK PLAN DATED: Q Q APPLICATION ACCEPTED BY .DATE I SU v. = AREA O v GROUT INSPECTION BY FINAL EC OW B1` DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE 2.°t o Z VIA .� 5 0 • 30.09 sR# 0 C-57 V WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 11/5/07(WEB) WELL PERMIT APP . 1 �