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C# San Joaquin County <br /> Environmental Health Department SITE <br /> ' 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 �� ATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd E�= <br /> IT IV <br /> Well Permit Application FE-q Z -9 dot <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUECPAjVjF fi'li��(11, <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. Tl�tg^3p}►� �rA9�mpliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental€i�'dltFt fc <br /> WELL Location East Waterloo Roadssessors <br /> Cross Street Cherryland Aveave City Stockton Zip 95215 Parcel# 101-021-32 <br /> PROPERTY <br /> z c Address6 f (akt�c� . T —City4-OClr <br /> f Zip8-";Z 2-Phone#2-01'33Lj319& <br /> C-57 Contractor Mitchell Drilling Address 7900 Myrtle_.Ave City Eureka Zip95503 Lic#672617Phone# 707-444-9040 <br /> Consultant ISub Cntr dvaneed ceoEnvironmentalAddress 837 Shaw Rd. CityStockton Lic# Lgg227 Phone# 209-467-1006 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,NAND-AUGER,OTHER*) D DESTRUCTION (choose type below) <br /> Q SOIL BORING# Q OVER-BORE. DIAMETER <br /> 4]WELL# MW-10 Q PRESSURE GROUT <br /> Q*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> B MONITORING [FHOLLOW STEM DIA,OF BOREHOLE'8" D MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:_2" <br /> Q EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS SCD 40 TYPE OF CASING: Q STEEL B PVC D OTHER: <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 60' TREMIE TYPE TO BE USED: 5AUGERS Q HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED:"D Yes Q No (NOTE: MAXIMUM FREE-FA// DEPTH IS 301) <br /> Q SOIL BORING D HAND AUGER GROUT SPECIFICATIONS Portland Type 21 <br /> D OTHER: D OTHER APPROX.BORING DEPTH 851 QfBOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NA (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 4U 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�Rules n Regulations) and all applicable California State Laws.- <br /> Signed x Title/CompanyStaff Scientist/Advanced--GeoEnyironmental <br /> r . <br /> Print Name AllV Colavita Date -p2liyn8 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: t G COPY <br /> WORK PLAN DATED: r <br /> Application Accepted By Date Issued2,1 a I Area <br /> Grout Inspection By Date 11 Final Inspection By_ ( Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: z_ <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 5EC'D BY DATE' 'PERMITI SERVICE REQUEST# INVOICE <br /> �sral { �t z6g�Y ` -SR# <br /> sv +vo <br /> C-57- W--WAIVER— C-57 Letter of Authorization to sign permit ✓Encroachment doc___ <br /> EHD 29-02-001 <br /> 6122/04 <br /> i <br />