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D San Joaquin County R�4EP DILE COPY <br /> Environmental Health Department FEB 2 5 2008 SITE <br /> 600 E.Main Street,Stockton, CA 95202-3029MITIGATION <br /> w <br /> (209)468-3449 Fax:(209)468-3433 Web: ww.sjgov.or�dNA/)EP4T HEALTH <br /> WiF640P MIT/SERVICES UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED OFF. CO ZQui <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicafion 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 /> County R�i,9ht�-9f-Way,plmwood Ave. Elmwood/Franklin Assessors n ^�Q� <br /> WELL Locati�I1,7f f,(,JY 00 Cross Street City Stockton Zip 95204 Parcel# 01 R <br /> n front of 2128, 2136 E 2142 Elmwood Ave. <br /> PROP <br /> Owner San Joa in Count 1810 E. Hazelton Ave. Stockton <br /> Owner � Y Address City Zip 95201 phone# 209-468-3000 <br /> C-57 Contractor A.G.E. Address 837 Shaw Rd. City Stockton Zip 95215Lic# 680227Phone# 209-467-1006 <br /> Consultant/Sub Cntr A.G.E. Address 837 Shaw Rd. City,Stockton LICA` 680227 Phone# 209-467-1006 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> xIINEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> a)ISOIL BORING# _ O OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> O'ONerr.,V 1 5 GROUT SPECIFICATIONS <br /> COMMENTS: See EHD-Approved Work Plan, dated 15 January 2007 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE?' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 5' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 4RUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 43 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> XIp6OIL BORING aHAND AUGER GROUT SPECIFICATIONS TYPE II NEAT CEMENT (PORTLAND) <br /> 0 OTHER: D OTHER APPROX.BORING DEPTH 5' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (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. <br /> I hereby Certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina-n`ces, Rules and Regulations, and all applicable California State Laws. <br /> Signed x�,tltrlll ,,� �'9.,..._ Title/Company ADVANCED GEOENVIRONMENTAL, INC <br /> Print Name TIMOTHY J. CUELLAR Date 25 FEBRUARY 2008 <br /> DEPARTMENT USE ONLY �' / NON J6SITE MAP IN UNIT IV FILE, ADDRESS: ZlS/ L,dLo.�-!�, (Gcf� /� — LO� <br /> WORK PLAN DATED: <br /> Application Accepted By _. Date Issued 3- <br /> q— <br /> O Area <br /> Grout Inspection By Dab 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 /> sod *1 383.' 2�Ir Gti� z 25 sR# 4.3 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to Sign permit_Encroachment doc'p-5•og'w'6 9 <br /> EHD 29-02-001web p��".v� c <br /> 6/22/04 '/ : •15.0 a <br />