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10/16/2006 THU 13: 53 FAX 20946 133 SJC EHD 12002/Cpo <br /> SAN JOAQUIN COUNTY <br /> 2 1? ENVIRONMENTAL HEALTH DEPARTMfT:,- SITE <br /> • 600 East Main Street, Stockton, CA 95202-3QQ��r �, ITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:WWW.sigOV.org/6hd -,t;o <br /> UNIT IV <br /> WELL PERMIT APPLICATION ` 4 2008 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATErIb(SW�1 " '_�t r�I_i'i(,IN <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is M�de'In compliance with San <br /> Joaquin County Development Title,chapter 9.1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor's <br /> Well Location 336 EAST LOCUST STREET Cross Street NORTH CENTRAL STREET City LODI Zip 95340 Parcel# 04311105 <br /> Property iP3 -+ 0FKV ohPo, CA, }D <br /> Owner LUCY THATER Address 336 EAST LOCUST STREET City LODI Zip 95240 Phone# (209) 339-4407 <br /> C-57 Contractor PRECISION SAMPLING, INC Address 2365 WIGWAM DRIVE City STOCKTON LIC# 6363,37 Phone (209) 465-8712 <br /> Consultant/Sub CntrADVANCED GEOENVIRONMAi[4TALSS 837 SHAW ROAD City STOCKTON LIC# 680221 Phone (209) 467-1006 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# OVER-BORE DIAMETER <br /> ❑WELL# W PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> Pressure grout one 65 foot monitoring well (KI-3) <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX,BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS:- CONDUCTOR CASING PROPOSED (if YES,Iisl specifications in comment section) <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,an I applicable gallf rnia Laws. <br /> Signed � i Title/Company STAFF SCIENTIST/ADVANCED GEOENVIRONMENTAL INC <br /> Print Name Date /C)hyh>r <br /> // DEPARTMdENTr USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: A rp <br /> WORK PLAN DATED: 4!-t 71 2PO <br /> APPLICATION ACCEPTED BY DATE ISSUED 00P AREA <br /> GROUT INSPECTION BY FINAL INSPEECTIO BY p DATE <br /> DESTRUCTION INSPECTION B DATEG����a <br /> COMMENTS/CONDITIONS: an kel-1V C� 5 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES EE INFO A T REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> C 57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD29-01 11/5/07(wE C p I �/ X14 3 Z 3 /�/4/O ly WELL PERMIT APP <br /> 40 a9•bo3i5 00 <br /> - <br /> 3 7 <br /> � ��So <br />