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U Oan Joaquin County • <br /> r� Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> 1 a Well Permit Application ft NOV ' <br /> Pp <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED }(12' 06 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. Tgis OpJi Ia mp�e_R�pliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental FiaRl( ENT Y <br /> WELL Location 2478 East Oak Street Cross Street Filbert CityStoctkon Zip Parcet+ <br /> PROPERTY igler & Wad, LLC 2707 E. Fremont St Stockton 95205 <br /> Owner Address City Zip Phone# <br /> C-57Contractor Mitchell Drilling Address7900 Myrtle Ave Cih,Eureka Zip 95503 Lic#672617 phone# 707-444-9040 <br /> Consultant/Sub Cntr Adv GeoEnvironmenta]Address 837 Shaw Road City Stoctkon Lics Phone# 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•) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# Mw-1 through MW-5 aPRESSURE GROUT <br /> 0 <br /> *Other GROUT SPECIFICATIONS <br /> COMMENTS: — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 2-inch <br /> MONITORING If HOLLOW STEM DIA.OF BOREHOLE-8.2b 0 MULTIPLE CASINGS 0-MULTI-LEVEL WELL CASING DIA: <br /> p EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCH 40 TYPE OF CASING: 0 STEEL UPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 40/85 TREMIE TYPE TO BE USED: ffAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Cement <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 65 / 90 OCBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NA (if YES, list specifications in comment section) <br /> COMMENTS: 4 Wells to 65 feet, 1 well to 90 feet bag <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 Ordinan Land egulations, and all applicable California State Laws. <br /> Signed x -/d'#'«� Title/Company vice President <br /> Print Name <br /> Robert Marty j Date 11-17-06 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY. AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SR# <br /> C-57— WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />