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08/11/2009 TUE 10: 00 FAX 2094F43433 SJC EHD 14001 <br /> *** FAX MULTI TX REPORT *** <br /> *************************** <br /> JOB NO. 2784 <br /> PGS. 1 <br /> TX/RX INCOMPLETE ----- <br /> TRANSACTION OK ----- <br /> ERROR 4671118 <br /> 4671118 <br /> "'" SAN JOAQUIN COUNTY <br /> r; <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> Y� I 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.s' ov.MC-� UNIT IV <br /> D <br /> WELL PERMIT APPLICATIO n'1r (� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE"A 6 2�u0C9 { <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describe I i3tt}a;�I�TIh{compliance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmet t c AsI )%-0.( I 0 <br /> Well Location 219 Park Street Cross Street Hunter City Stockton Zip 95203 Parcel# <br /> Property <br /> Owner Ann Thompson Address P.O. Box 1875 City Lodi Zip 95241 Phone#1-209-931-8550 <br /> C-57 Contractor Gregg Drilling Address 950 Howe Road City Martinez Lic#485165 Phone 1-925-313-5800 <br /> A vance GeoEnvrionmental Inc. <br /> Consultant/SubCntr Address R37 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 /> ®NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ©WELL# MW-13, MW-14 ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ®MONITORING ®HOLLOW STEM DIA.OF BOREHOLE 8" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2 <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS N/A TYPE OF CASING:❑STEEL IS PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL Variable 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 /> El SOIL BORING El HAND AUGER GROUT SPECIFICATIONS Portland Cement <br /> c� <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 45 and 85 ft. bspJ 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 have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> RegulAigns and all applicable California Laws. <br /> Signed'._ I 1 1 Title/Company J IJ CU�dcfrf I ��� <br /> Print Name �� \ \Cl:�llQsLC-.- Date <br /> t <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: �yl1 <br /> 61 /1 r l _ <br />