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off'°"°IV,�. San Joaquin County <br /> 'i Envit,.dmental Health Department `..r SITE <br /> ; 1 600 E. Main Street, Stockton, CA 95202-3029 MITIGATION <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 /> 1011 North Broadway Fremont Assessorstt <br /> WELL Location Y Cross Street City Stockton Zip 95205 Parcel# <br /> PROPERTY <br /> Owner Frank Spincrolo Address 1011 N. Broadway City Stockton Zip 95205 phone# 465-5675 <br /> C-57 Contractor Advanced GeoEnvironmentaAddress 837 Shaw Road City StocktonZip 95215Lic#680227 Phone#467-1006 <br /> Consultant/Sub Cntr Advanced GeoEnvironental Address 837 Shaw Road CitY Stockton Lic# 680227 <br /> Phone# 467-1006 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> TNEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER.*) 0 DESTRUCTION (choose type below) <br /> [',SOIL BORING# 2 soil borings 0 OVER-BORE, DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: Work plan dated 25 May 2007; approved -by_letter dated 05 June-2007 - - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2" 0 MULTIPLE CASINGS <br /> 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA <br /> 0 VAPOR TYPE OF CASING: 0 STEEL �PVC 0 OTHER: <br /> 0 MUD ROTARY DEPTH OF GROUT SEAL 20; 65 TREMIE TYPE TO BE USED: U�AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0:PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes icNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> [:SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland cement <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH 20; 65 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED NA (if YES,list specifications in comment section) <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 Or¢iances lesa�d Regulations, and all applicable California State Laws. <br /> Signed x / �_///>� <br /> .�'^ " ���-�'� Title/Company Vice President/Advanced GeoEnvironmental, Inc. <br /> Print Name l c-f/ r �.f j71 � <br /> ate <br /> DEPARTMENT <br /> fj nerQV,' <br /> DEPARTMENT USE ONLY J <br /> SITE MAP IN UNIT IVFILE1 ADf,ORESS:� - � /6�,, Az <br /> WORK PLAN DATED: Zs/ 7 L ,p��/I��Nf�fiEtij HEALIF <br /> Application Accepted B 1 Date Issued_�e,/4'/p/ Area / <br /> Grout Inspection By Date d Final Inspection By r 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 /> 5s0ft - �- d aj <br /> C-57_ WC=WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EHD 29-02-001 web <br /> 6/22/04 <br />