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oe0. '"•.� San Joaquin County • <br /> nl �% Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Jl.jr'•! t -, <LINTIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.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 County Environmental Health Department. <br /> Wilson Way & Assessors <br /> WELL Location 101 S. Wilson Way Cross Street Market St. pity Stockton Zip 95205 parcel# 051-253-008 <br /> PROPERTY <br /> Owner Paul Surinder Address 2741 Otto Drive pity Stockton Zip 95209 Phone# 209-462-7327 <br /> C-57 Contractor Gregg Drilling Address 950 Howe Rd. City Martinez Zip 94553 Lic# 485165 Phone# 925-313-5800 <br /> Consultant/Sub Cntr A.G.E. Address 837 Shaw Rd. City Stockton Lic# Phone# 209-467-1006 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> THEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> YSOILBORING# B-7, B-8 & 3-9 DOVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: SEE WORK PLAN DATED 10 JANUARY 2008 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 8 FF 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: n STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 401 TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: PYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> )TSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS PORTLAND TYPE II GROUT <br /> 0 OTHER:_a OTHER APPROX.BORING DEPTH 40 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO <br /> (if YES,lis[specifications in comment section) <br /> COMMENTS: SEE EHD APPROVAL LETTER DATED 21 MARCH 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 work will be done in accordance with San Joaquin <br /> County Ordinances, RuleRe <br /> Rules and Regulations,and all applicable California State Laws. <br /> Signed x- / a �W-A/71/'�-- Title/Company PROJECT GEOLOGIST/A.GG.E. <br /> Print Name TIMOTV J. J/ICUELLAR Dale 011 01 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 10 ( 5. W. ISGrI (A <br /> WORK PLAN DATED: �� <br /> Application Accepted By /V✓G����f Jo'� Date Issued 17rT"ne 26v8 Area I'Y53 <br /> Grout Inspection By�l�Date li o inal Inspection By A14 At Date <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/SERVICE REQUEST# INVOICE <br /> 3603 $ 2911 0 383 °° 2744 Z CN7r�- G y og SR# 0O 5+57I <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />