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Aq"`" r)SAN JOAQUIN C UNTY i <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> . :, 600 East Main Street, Stockton, CA 96202-3029 MITIGATION <br /> Telephone:(209)468-3454 Fax: (209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 C unty Environmental Health Department. 117-090-14 <br /> Assessors <br /> Well Location 280E West Lane cross Street E. Harding Way Gity StocktonZ;p 95204 parcel# 127-280-34 <br /> Property <br /> Owner San Joaquin Regional Rail CommissiOAddress 949 East Channel Street ;ty StocktonZip 95202 phone# 209-944-6220 <br /> C-57 Contractor Gregg Driling Address 950 Hower Road ;ty Martinez Zip 94553 Lic# 485165// Phone <br /> ConsultantlSub Cntr l)+(Z�j AddressZSr�O C�aket.k�7�7 — ity _Saefv X 33 Lic# Phone���4 <br /> 3Gb <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 see attachments <br /> ❑WELL# PRESSURE GROUT see attachments <br /> ❑*OTHER GROUT SPECIFICATIONS see attachments <br /> ❑EXPLOSIVES DETONATING CARD <br /> Dnnt�-s t Drr,l�.�- r OwtW-fit AwtW-�t/tprnw-!2 IArt�l -1�� (,,�i��aNP�G�.il��o <br /> COMMENTS: <br /> va;r 47 rkz--c FVtM s 1 i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPEC! 'I CATIONS see attached tab a <br /> KMONITORING $HOLLOW STEM DIA.OF BOREHOLE -tCJ_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA_Z"-j" �r <br /> ©EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING-❑STEEL MPVC ❑ OTHER <br /> []VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL -' VC# TREMIE TYPE TO BE USED©AUGERS❑HOSE ` <br /> ❑AIR SPARGE)OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:; es ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX_BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (it YES,list speciflcaUons in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS V` <br /> 48 WORKING HOURS NOTICE REQUIRE 3 FOR INSPECTIONS ' 4I <br /> 1 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 appli Ie California Laws. <br /> Signed v Title/Company <br /> URS Corporation <br /> Print Name AnthonyMindfing Date 11/17/09 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: -2-$0 1 Pi <br /> WORK PLAN DATED: ktifinfeg <br /> APPLICATION ACCEPTED BY LLud A e C4 DATE ISSUED 1.1 Z`( AREA <br /> GROUT INSPECTION BY c } �� ll FINAL INS PECTION BY' _-_ _ ±.. DATE <br /> DESTRUCTION INSPECTION BY N try DATELl7 <br /> COM M ENTSICON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE 0 INVOICE <br /> 35v2 C,C, V ISA I z'1 toq SR# SV63 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10128/09 WELL PERMIT RPP <br />