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,f <br /> } F I)Y <br /> ora'''"• r SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL. HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-34313 Web:WWW.SigoV.org/ehd UNIT IV <br /> tik qf4'•� <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES t 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 County Environmental Health Department 117-090-14 <br /> E. Harding Way � Stockton 95204 Assessors 127-280-34 <br /> Well Location 2801 West sane cross street i; Y c' zip Parcel� <br /> Property San Jos uin A ional Rail Commissio 949 East Channel Street Stockton zi 95202 Phone# 209`944-6220 <br /> Owner 4 � liddress C. P <br /> C-57 Contractor Gregg Driling Address 950 Howe Road City Martinez Zip 94553 Lic# 485165/ Phone <br /> Consultant/Sub Cr* Address Z' ^ " City �p Lic# Phone ��`t�� !ZJm <br /> 5k 1cc <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) JX DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL 9ORINGIF 91OVER-BORE DIAMETER see attachments <br /> ❑WELL# 53 PRESSURE GROUT see attachents <br /> ©*OTHER GROUT SPECIFICATIONS see a ac men <br /> ❑EXPLOSIVES DETONATING CARD <br /> bmw-s, Dna w- , Awl w`°It Ly+t -I l pnl w-m I Ar"k) I,.a'i <br /> COMMENTS: IF <br /> -LA C7 I r <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICAT1 NS see attacitea tatpTe <br /> MONITORING $HOLLOW STEM DIA.OF BOREHOLE dEjg [3 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DWZ: <br /> ❑EXTRACTION Q AIR HAMMERDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL WPVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL IM ^TREMIE TYPE TO BE USED[3 AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE 0 PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED'.AYes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> I]SOIL BORING C3 HAND AUGER GROUT SPECIFICATIONS''l fg T d A—,M&!� <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR CI STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,rat speeific W*in mrimem secfia) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <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 Calftrnla La <br /> Signed 0y ` Title/Company URS Corporation <br /> Print Name Anthon Mindlin Date 11/17/09 <br /> DEPARTMENT USE QNLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z-$0t e" <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY (L. a c e�_ DATE ISSUED t i 7L`{ AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV DI BY DATE PERMIT/SERVICE# ]INVOICE <br /> 3 02 yb'�:C,a VISA tt :y Y SR# ff 3 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />