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,0SAN JOAQUIN COUNTY <br /> ENVVONMENTAL HEALTH DEPARTMEN— SEP 3 2009 SITE <br /> bwv� 600 East Main Street, Stockton, CA 95202-3029 EfV MITIGATION <br /> Telephone: (209) 468-3449 Fax: (209) 468-3433 Web:WWW.S OV.O E1l11T IV <br /> WELL PERMIT APPLICATION SEP _3 2009 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSU DN JOAQUINCOUNTY <br /> ENVIRONME SENT <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applli. �G�t�n compliance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> San Joaquin Street (see attached) Assessor's <br /> Well Location Cross Street Park City Stockton Zip 95202 Parcel# N/A <br /> Property <br /> Owner City of Stockton Address 345 North E1 Dorado Steity Stockton Zip 95202 Phone#1-209-937-8561 <br /> C-57 Contractor Gregg Drilling Address 950 Howe Road City Martinez Lic# 485165 Phone 1-925-313-5800 <br /> Advanced GeoEnvrionmental Inc. <br /> Consultant/SubCntr Address 837 Shaw Road City Stockton Lic# NA Phone 1-209-467-1006 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> R NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑ SOIL BORING# ❑ OVER-BORE DIAMETER <br /> ©WELL# MW-15, MW-16, MW-17 ❑ PRESSURE GROUT <br /> F]-OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> R MONITORING ®HOLLOW STEM DIA.OF BOREHOLE 8 11 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2 11 <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS N/A TYPE OF CASING:❑STEEL (N PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL Variable TREMIE TYPE TO BE USED El 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 Portland Cement <br /> 45, 85, 110 ft. bsg <br /> El OTHER: ❑OTHER' APPROX.BORING DEPTH ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment 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 have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> -- <br /> Signed - Title/Company <br /> ''y t <br /> Print Name �� x�l l , , r1 l''11G Date C1 i 7 <br /> t i <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: -Z: <br /> WORK PLAN DATED: Cc- 3 O Zo9 <br /> APPLICATION ACCEPTED BY D,k ISSyEa JAIW111111 AREA 36 l <br /> GROUT INSPECTION BY FINAL INSPECTION B DATE 16 t <br /> DESTRUCTION INSPECTION BY DATE 1 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# REC 'D BY DATE PERMIT/SERVICE# INVOICE <br /> o gq.oZ7 �{ •°, 00 7 SR#'�r5 It,� <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZA ION TO SIGN PERM ENCROACHMENT DOC <br /> EHD 29-01 1115107(WEB) WFI I PFPMIT APP <br />