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r <br /> Joaquin County- <br /> Envirdia-wental Health Department SITE <br /> I ��;;� , 0 East Main Street, Stockton, CA 9 202-3029 MITIGATION <br /> .: � • ,1i-_�' ItOl 68-3449 Fax: (209)468-3433 Web: WV1W.sjgov.org/ehd <br /> L UNIT IV <br /> &4AR 1. Well permit Application <br /> 1i-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application iso I'd h in County for a permit to construct and/or install thework described. This application is made in Compliance with San <br /> 646�4Joaquin County <br /> q, ,*10 i�, ter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location ross Street E,Hardin.�Way ily Stacldon Zip Asesso <br /> 95204 Parcel rs <br /> PROPERTY I <br /> owner Mill Creek Development Address 343 East Main St. Ste 318 City tockton zip 95202 Phone# 209-401-4102 <br /> C-57 ContractorGregg Drilling and'eStirlkAddress 950 Howe Road City Martinez Zip 94553 Lic#485165 Phone*925-313-0302 <br /> Consultant/Sub Cntr URS Corporauori Address 2870 Gatewav Oaks Dr it%Sacramento Lic# Phone# 916-812-8037 <br /> GIS Coordinates:X 'Y __ Township Range Section <br /> WORK TO BE PERFORMED: <br /> X'NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> OIL BORING# 0 OVER-SORE. DIAMETER <br /> ELL#DMW-10 11 12 13 and 14 a PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> XMONITORING HOLLOW STEM DIA.OF BOREHOLE 8 in a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2 in_ <br /> 11 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 11 STEEL XPVC 0 OTHER: <br /> 0 VAPOR 11 MUD ROTARY DEPTH OF GROUT SEAL Ann 40 TREMIE TYPE TO BE USED: XAUGERS Q HOSE <br /> []AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: :RYes fl No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br /> (1 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS "a <br /> a OTHER: OTHER APPROX.BORING DEPTH OLTED TRAFFIC BOX or 13 STOVE PIPE <br /> CONDUCTOR CASING PROPOS D (if YES,list specifications in comment section) <br /> COMMENTS: Local Agency Case No. 1882.Please refer to worm D61 dated Februm 13 2008 <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 wo will be done in accordance with San Joaquin <br /> County(Nina es, Rules an Regulati sand all applicable Califo nia State Laws. <br /> Signed x L Title/Cornpan _ Senior Geolog[st[UR.SCoipom ion <br /> Print Name Antho Mindl' Date March 17,2008 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDESS: bl w, ( L ons <br /> WORK PLAN DATED: l )_11->1 0$ rw1.'- tA) I t t o t�.�1+ ( Yw'^�` Iv <br /> Application Accepted By_ Vt o 'y Dat Issued I, ✓1� Are 1' <br /> Grout Inspection By Date Final Inspection By /1.•� Date to <br /> Destruction Inspection By _Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> ��.J � �1�.�0 luC� SR#C>05:V � <br /> C-57 ✓ WC -WAIVER C-57 Letter of Authorization to si n permitZ Encroachment doc <br /> EHD 29-02.4111 WEB <br /> 9/11/2007 <br />