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.� SAN JOAQUIN COUNTY <br /> ENVII :ONMENTAL HEALTH DEPARTMENT p �I=fir, ^ �I{ ,` <br /> 600 East Main Street, Stockton, CA 95202-3029 ���' "iGA�F10N <br /> Telephone: (209) 468-3449 Fax: (209) 468-3433 Web:www.si oq v org//ehd <br /> jul- � I�Ig1fidV <br /> WELL PERMIT APPLICATION ENVIRONI LENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PER -ill it I VICES <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 /> Assessor's <br /> Well Location 248 Park Street Cross Street Hunter City Stockton Zip 95203 Parcel# 139-060-35 <br /> Property 1-209-948-1636 <br /> Owner Remo Canepa Address 1536 North Hunter St. City Stockton Zip 95204 Phone# <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 R,;7 Shaw Rnad 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 /> P;Q WELL# MW-8, MW-9, MW-10, MW-11, MW-12 ❑ PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> N <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS fl <br /> oG <br /> ®MONITORING ® HOLLOW STEM DIA OF BOREHOLE 8 ElMULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2 <br /> ❑ EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS NSA TYPE OF CASING:❑ STEEL ® PVC ❑ OTHER V <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL Variable TREMIE TYPE TO BE USED El AUGERS❑ HOSE <br /> ❑AIR SPARGEJOZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:M Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Portland Cement <br /> 45,85, and 110 ft. bsg <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 1 have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all applicab a California Laws. e <br /> Title/Company 'lqul'rc%,!/� /Ind <br /> 1 `� <br /> Print Name ��.C `�� U.MV P Jr� Date �1- - 09 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE.ADDRESS: —LAS <br /> WORK PLAN DATED: D <br /> APPLICATION ACCEPTED BY v DATE AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> [ACCOUNTING ONLY: AID# FAC# <br /> E CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> C-57� WC -WAIVER C57 LETTER OF AUTHOR14ATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 25-01 11/5/07(WEB) WELL PERMIT APP <br />