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d. q�• r� SAN JOAQUIN COUNTY <br /> 'z<l ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> i 600 East Main Street, Stockton , CA 95202-3029 D <br /> [7p n TION <br /> Telephoner (209) 468-3449 Fax: (209) 468-3433 Web: www.s' d I N <br /> LfFOR L��`,, u <br /> WELL PERMIT APPLICATION Ct ' JUL 2 6 2010 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE I�ilkl� hl"ENnTL�HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This aPPMV4RIVIV HEA <br /> ance with San <br /> Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. �l7 <br /> Assessor's <br /> Well Location 19 ouch el Dorado street Cross Street Fifth sc=eec City Stockton Zip 95206 Parcel # <br /> Property <br /> Owner MATAR , MOHAMMAD S & WAFAAddress 1901 S . EL DORADO ST City STOCKTON Zip 95206 Phone # 209 - 948 - 2619 <br /> Cw57 Contractor All Well Abandonment Address 3809 Pleasant Valley Rd City Placerville LIe # 848359 Phone 800 - 948- 1355 <br /> ConsultantSub Cnte,dwaaeea ceounwizonmentAddress B37 Shaw Road City Stockton Lie # 95215 Phone 800-511-9300 <br /> GIS Coordinates: X , Y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> ® NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER`) ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br /> ❑ SOIL BORING# ❑ OVER-BORE DIAMETER <br /> ❑x WELL # EW- 2 , EW- 3 [I PRESSURE GROUT <br /> ❑ *OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> cw <br /> G <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING 91 HOLLOW STEM DIA. OF BOREHOLE 10 e ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 2 " <br /> ® EXTRACTION ❑ AIR HAMMER/DRIVEN CASING THICKNESS Schd . 40 TYPE OF CASING: [] STEEL ® PVC [] OTHER <br /> ❑ VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL 11 - 21 ' TREMIE TYPE TO BE USED [] AUGERS ® HOSE <br /> ❑ AIR SPARGFJOZONE [] PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: El Yes ❑ No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑ SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS Portland Type TI en( <br /> [] OTHER: ❑ OTHER: APPROX. BORING DEPTH 40 -45 ' ® BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br /> CONDUCTOR CASING PROPOSED No (if YES, list specifications in comment section) <br /> COMMENTS: umal Ph (ground ter and soil ) Extraction Wells EW d EW fay interim remediation , <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 I accordance with San Joaquin County Ordinances, Rules and <br /> Regulations, ar ll applicable Caiifo la kawsm <br /> Signed ( Title/Company Project Scientist <br /> Print Name Ally Colavita Date 07 / 26 /10 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: I " l D 1.. ( Dz7w4y a t 5Vb <br /> WORK PLAN DATED: ^ '(� Iw-tZA t YAPI 0 <br /> APPLICATION ACCEPTEDB /_ �,�//u�'LJJAALW(/l/L DATE ISSUED -t�1 �Z$ I, ( ,� AREA ^S � J <br /> GROUT INSPECTION 8Y ���sw"C- J1 � FINAL INSPECTION BY / J-v✓ DATE g It-Ita <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID # FAC # <br /> PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE PERMIT/SERVICE # INVOICE <br /> ss • t W�_� q o� 1So � a :BIrJ SR# (oo (.2l <br /> C-5 WC -WAIVER. C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07 (WEB) WELL PERMIT APP <br />