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`'!"...� fkan Joaquin County <br />Environmental Health Department SITE <br />" - \ 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br />468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />Well Permit Application <br />FUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is h iii n,Jbaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />Joaquin County D _ nt Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department, <br />Assessors <br />WELL Location 2651 South Airport Way Cross Street Tenth City Stockton Zip 95206 Parcel# 16912003 <br />PROPERTY <br />Owner Earthgrains Baking Co. Address 2651 S. Airport Way City Stockton Zip 95206 Phone# 209-547-2202 <br />C57485165 <br />C-57 Contractor Gregg Drilling Address 950 Howe Road Cityhlartinez Zip 94553Lic# Phone# 925-313-5800 <br />Consultant/ Sub Cntr PSC Address 210 W. Sand Bank Rd. CityColumbia Lic# Phone# 618-281-7173 <br />GIS Coordinates: X Y Township 1 North Range 6 East Section 22 and 23 <br />WORK TO BE PERFORMED: <br />(NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />SOIL BORING # CPT -4 through CPT -7 0 OVER -BORE. DIAMETER j� <br />0 WELL # 0 PRESSURE GROUT v <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: Four CPT borincas and up to 20 adjacent hydropunch borings <br />V <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2" 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 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE ff PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />I(SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Neat cement <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 100' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. r` <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 a d Regulations, and all applicable California State Laws. <br />Signed x �2 Title/Company Project Manager <br />Print Name Paul Anderson Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 26 5-1 S. A ir,ao+ U%w <br />WORK PLAN DATED: t12LI / ,ryS�, .24 ,2.008 <br />Application Accepted By CB?t�nd��%%Y1,'=(dt L�iriGGl Date Issued 3 —ao -08 Afea 14-5,1 _ <br />Grout Inspection By V( d*A f i & rnG (. a V t -n Date 4 - I - d $ Final Inspection By e v r 1 ate 4 <br />Destruction Inspection By Date 1 <br />COMMENTS /CONDITIONS: O <br />ACCOUNTING ONLY: AID# FAC# ' <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE QUEST # INVOICE <br />350 I <br />IF 89. <br />O <br />3-;z0 v8 SR# daS3 S <br />C-57 WC WAIVER_ C-57 Letter of Authorization to sign permit_ <br />EHD 29-02-001 WEB <br />9/11/2007 <br />