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1/ <br /> San Joaquin County <br /> Envir`onmental Health Departmen , SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MI IGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> ' NIT IV <br /> Well Permit Application 2 '©EC 18 PH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM D TF ISSUfid UU H COUNT Y <br /> I�LNT AL <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the wordy �i OF <br /> -14 in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County E� ' " ea tl h Department. <br /> I rh;n -ity�Stockton Pro �rt} see comments) Assessors <br /> WELL Location Q_� ,� 0/Adfyross Street City J �K1°7y�Zip�r Parcel# <br /> PROPERTY CITY OF STOCKTON (See attached encroachment permit) <br /> Owner Address City Zip Phone# <br /> C-57 ContraAdvanced GeoEnvironmen Address 837 Shaw Road City Stockton Zip95215 Lic# 680227Phone# 467-1006 <br /> Advanced GeoEnvironmental 837 Shaw Road Stockton 680227 467-1006 <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X -'y Township Range Section <br /> WORK TO BE PERFORMED: <br /> Yb NEW WELL/BORING_4(cPB,5 EOB ROB ,H7YDRBOPUNCH,HAND-AUGER,OTHER*) Q DESTRUCTION (choose type below) <br /> 3VSOIL BORING# Q OVER-BORE. DIAMETER <br /> Q WELL# Q PRESSURE GROUT <br /> Q *Other GROUT SPECIFICATIONS <br /> COMMENTS:Adjacent to 2057 So E1 Dorado/2070 So E1 Dorado/ 9 Delhi Street (see City Encroachment Permit) <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE 1.25110 MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:____ <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TD TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE )VUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> )4SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS Type II portland <br /> Q OTHER:_0 OTHER APPROX.BORING DEPTH First GW (30')Q BOLTED TRAFFIC BOX or Q 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. <br /> hereby certify that I have pre this application and that the work will be done in accordance with San Joaquin <br /> County Ord M'x= <br /> lations,and all applicable California State Laws. <br /> Signed x Title/Company PM/ADVANCED GEOENVIRONMENTAL, INC,,, ,���n�nJT <br /> Print Name ARTHUR DEICKE Date 18 DECEMBER 2006 RECEIVED <br /> DEPARTMENT USE ONLY <br /> DEC 1 8 2006 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: SAN JOAQUIN COUNTY <br /> NTAL <br /> /^, I 1 HEALTH DEPARTMENT <br /> Application Accepted By - 't^ 4Date Issued vxAm g I o Area t 1 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> [ACCOUNTING <br /> ONLY: AID# FAQ FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> sR# <br /> C-57Ltf WC V0rVAIVERV'k C-57 Letter of Authorization to sign permit Encroachment doc ✓ <br /> EHD 29-02-001 <br /> 622/04 <br />