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*San Joaquin County 0 <br /> Ei ivironmental Health Department SITE <br /> m 304E t Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> Well Permit Application <br /> NON-RE UNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin Cc unty 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 /> Assessors <br /> WELL Location 1607 Turnpike Row Cross Street Lincoln City Stockton Zip CA Parcel# 165-040-04 <br /> PROPERTY <br /> Owner Greg Gaut Adi rens 18120 Arrigone Way CityLinden Zip 95236 Phone# 209-466-4601 <br /> C-57 Contradomd.m,ced oe.sn,iro.mentaj Address 837 Shaw Rd. Citystockton Zip95215 Lic#680227 Phone#209-467-1006 <br /> Consultant/Sub Cntr Same as above Address City Lic# Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> I3 NEW WELL/ BORING (CPT, GEO ROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> A WELL# TW-1 TW-2 a PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION PE CONSTRUCTION SPECIFICATIONS <br /> E MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE?'! u MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 1.5" <br /> a EXTRACTION a AIR HAMMER/D RIVEN CASING THICKNESS 3014 4 a TYPE OF CASING: a STEEL 0 PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL SFC-TD TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> 0 AIR SPARGE/OZONE ffPUSH POINT(C D or CPT)GROUT SEAL PUMPED: E Yes ff No (NOTE: MAXIMUM FREE-FA// DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Portland Type II <br /> 8 OTHER:Temporary a OTHER APPROX.BORING DEPTH 30' 0 BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORING 3 REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 41UW RKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepare I this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances R es a d Re ulationsI and all applicable California State Laws. <br /> Signed Title/Company Staff Scientist/Advanced GeoEnvironmental <br /> Pdnt Name Alison Colavita Date n4/n5/n7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 1607 Turnpike Road <br /> WORK PLAN DATED: Work Plan Addendum 04-09-2002, Approved on 05-07-2002 <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date �- <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT RE TIED CHECK# 5EC'D BY DATE PERMIT SERVICE R5 ICE <br /> SR# <br /> C-57 WC---WAIVER— -57 Letter of Authorization to sign permit_Encroachment clot_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />