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SaD v — SAN JOAQUIN COUNTY ENVIkvNMENTAL HEALTH DEPARTMEN I m SITE z 600 East Main Street, Stockton , CA 95202-3029 MITIGATION �. Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.s I T IV WELL PERMIT APPLICATION h1jAY 1 7 2010 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE I ED T�- u Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This ap I1 1 Pu'deLtR(F4"Ice with San Joaquin County Development Title , chapter 9-1115.3 and the Standards of San Joaquin County Environmental Heal th4 �S/��sbt' (City of Stockton ROW) S Well Location North aide of fEa Fifth St . Cross Street S . El Dorado Street City Stockton Zip 95206 Parcel # NA Property Owner City of Stockton Address 22 E . Weber Ave . City Stockton Zip 95202 Phone # 209 - 937 - 8411 C--57 Contractor All Well Ahandonment Address 3809 Pleasant valley Rd City Placerville DC # B48359 Phone 800 - 948 - 1355 Consultant/Sub Cntmdvanced GeoRnviroonEvt Address B31 Shaw Road City Stockton Lic # 952is Phone 800 -511 -9300 GIS Coordinates: X , Y Township Range Section WORK TO BE PERFORMED: E9 NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,:OTHER*) ❑ DESTRUCTION (CHOOSE TYPE BELOW) ❑ SOIL BORING# ❑ OVER-BORE DIAMETER 0 WELL # MW- 10 ❑ PRESSURE GROUT El *OTHER - GROUT SPECIFICATIONS COMMENTS: TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ® MONITORING ® HOLLOW STEM DIA. OF BOREHOLE 8 " ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 2 " ❑ EXTRACTION ❑ AIR HAMMER/DRIVEN CASING THICKNESS Schd . 40 TYPE OF CASING: ❑ STEEL EIPVC ❑ OTHER 0 VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEAL 70 ' TREMIE TYPE TO BE USED ❑ AUGERS ® HOSE ❑ AIR SPARGE/OZONE ❑ PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: El Yes ❑ No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) ❑ SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS Portland Type II ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 80 ' M BOLTED TRAFFIC BOX OR Q STOVE PIPE CONDUCTOR CASING PROPOSED NO (If YES, list specifications in comment section) COMMENTS: inatallation of off-site MW-lo in the City of Stockton ROW for thig qrqupdwater investigation at ONSIO , 1901 S . E1 Dorado St . Stockton NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and Regulations, and all applicable alif m teia Laws. Signed t�L+l L- Title/Company Project Scientist Print Name Ally Colavita Date 04128 /10 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE, ADDRESS: - _ _ iA EI Dor0. 04;P - - WORK PLAN DATED: at - APPLICATION ACCEPTED BY 1 DATE ISSUED lq AREA GROUT INSPECTION BY FINAL INSPECTION B ® DATE J DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS : ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE PERMIT/SERVICE it INVOICE o N SR# Oo.(o coif C- WC V -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC END 28-01 111W7 (WEB) WELL PERMITAPP