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fan Joaquin County <br /> z� Envir rental. Health Departmen _ SITE <br /> 600 E. Main Street, Stockton, CA 95202-3029 I� � i`�MITIGATION <br /> ' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/e <br /> 72 UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 9 YEAR FROM DATE ISSU � in' 1` y�i AL <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This app�i0i/49ade in compliance with San <br /> Joaquin County Development Title, Chapter 9-1195.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location 355 ENTERPRISE PLACE Cross Street Inau5trial Way City TRACY Zip 95304 Parcel# 212-210-08 <br /> 4 <br /> PROPERTY <br /> Owner MARAACH,MAHMOUD Address 2300 S RESERVIORPOMONA <br /> City Zip 93766 Phone# 909-465-1031 <br /> ;I <br /> C-57 Contractor ALL WELL ABANDONMENT . Address 3809 PLEASANT VALLEY RD Clty PLACERVILLEZip 95667 LIC#848359 Phone# B00-948-1355 <br /> Consultant/Sub Cntr ADVANCED GEOENVIRONMENTAL Address 837 SHAW ROAD City STOCKTON LiC# 680227 Phone# 209-467-1006 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: �I9'ofi <br /> p NEW WELL I BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER, OTHER*) DESTRUCTION (choose type belowIS_�yr <br /> i a SOIL BORING# DOVER-BORE. DIAMETER - 4 OLE <br /> Q WELL# a PRESSURE GROUT <br /> "Other GROUT SPECIFICATIONS TYPE II PORTLAND <br /> COMMENTS: WELLS TO BE DESTROYED: MW-1,MW-2,MW-3,MW-4,MW-5, & EW-1 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 11 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE a MULTIPLECASINGS (a MULTI-LEVEL WELL CASING D[A:------ <br /> a EXTRACTION ©AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ©STEEL o PVC It OTHER: <br /> d VAPOR d MUD ROTARY DEPTH OF GROUT SEAL li.TREMIE TYPE TO BE USED: a AUGERS 17 HOSE <br /> 0 AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: g Yes a No (NOTE: MAXIMUM FREE-FA/1 DEPTH IS 30') � <br /> Q SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> o OTHER:_0 OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or U STOVE PIPE I <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> y <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 4U WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> �t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances R s a gulationsl and all applicable California State Laws. <br /> Signed x , - Title/Company ADVANCED GEOENVIRONMENTAL, INC / PROJECT SCIENTIST <br /> Print Name ALLY COLAVITA Date 36 DECEMBER 2008 <br /> DEPARTMENT USE ONLY <br /> I SITE MAP IN UNIT IV FILE, ADDRESS: 35-r Eaie-r-D r ;s e E!a cc, <br /> WORK PLAN DATED: <br /> Application Accepted By Vi G+[1 r +'-r1 a Date Issued: f 2–/ E3 -0 f3 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection Byyi�,}��►,� Ync� r�jlyM Date 12-27 �Q - <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# SECT)BY DATE .a PERMIT/SERVICE REQUEST# INVOICE <br /> X502 4a-�a <br /> 3 X15,00 X75. L(1411"o0 2923012-1s°-06 S' (205-6177 <br /> C-57,_ WC---WAIVER.— C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001web <br /> 6122/04 <br /> r <br /> k I <br />