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0 4U' . o San Joaquin County <br /> z `z Environmental Health Department SITE <br /> a: { 600 East Main Street, Stockton, CA 95202-3029 <br /> JUN t? rt �,,WTIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.s.igov.org/ehd UNIT IV <br /> 'F°" Well Permit A lication ENVIR�INr/IEIV MEAL H <br /> Application PERMT-3ERVIUS <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 /> 101 S. Wilson Way Wilson way s Assessors <br /> WELL-Location Y Cross Street market st. City Stockton Zip 95205 Parcel# 051-253-008 <br /> PROPERTY <br /> Owner Paul Surinder Address 2741 Otto Drive Chy Stockton Zip 95209 Phone# 209-462-7327 <br /> C-57 Contractor Gregg Drilling Address 950 Howe Rd. City Martinez Zip 94553 Lid/ 485165 Phone# 925-313-5800 <br /> Consultant/Sub Cntr A.G.E. Address 837 Shaw Rd. CityStockton Lic# phone# 209-467-1006 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> )"EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) p DESTRUCTION (choose type below) <br /> V�SOILSORING# B-7, B-8 6 B-9 DOVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0.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 81, 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR I]MUD ROTARY DEPTH OF GROUT SEAL 40' TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: sales 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> JYSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS PORTLAND TYPE II GROUT <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 90 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO <br /> (if YES,list 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, Rulesand <br /> (Reeg�u�la�t�ions,and all applicable California State Laws. <br /> Signed � a ` XIAO/— Title/Company PROJECT GEOLOGIST/A.G.E. <br /> Print Name TIMOT J.v CUELLAR Date vivo 3106 <br /> DEPARTMENT USE ONLY � <br /> SITE MAP IN UNIT IV FILE, ADDRESS: IO l 5• LJ. 1so.� (� <br /> WORK PLAN DATED: �%8 <br /> Application Accepted By /VtlGl Ae tUf✓Joy Dale Issued 70;,„e 2ov5 Area 1153 <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 REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> NO.3 rr ¢ 383 . 00 27/x( Z CNTR L Y/ 0$ SR# 00 5,4571 <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-omni WEB <br /> 9/11/2007 <br />