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10/16/2008 THU 13: 53 FAX 2094683433 SJC EHD 0002/(prp <br /> 0. SAN JOAQUIN COUNTY <br /> SITE <br /> ENVIRONMENTAL HEALTH DEPARTMI�T � <br /> 600 East Main Street, Stockton, CA 95202-302 i 1( <br /> SITE <br /> 1TIGATION <br /> \o P Telephone: (209)468-3449 Fax: (209)468-3433 Web:www.sj oq v.org/ehd t/L fi_ %' UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATErIbtSW /II''�I/ fLi?117:.; <br /> r1fY 11ivi: <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the worts described. This appiication Is trlad8'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 CENTS.AL STREET City LODI Zip 95240 Parcel# 04311105 <br /> Property F 3f 3, ACA&LP0 11h Pa CA, F 5�O <br /> Owner LUCY THATER Address 336 EAST LCCDST STREET City LODI Zip 9-240 Phone# (209) 339-4407 <br /> •. C-57 Contractor PRECISION SAMPLING, INC Add reSS 2365 WIGWAM DRIVE City STOCKTON LIC# 636387 Phone (209) 465-8712 <br /> Consultant/Sub Cntr DVANCED GEOENVIRONMAitBMSS 837 SHAII ROAD City STOCKTON tic# 680227 Phone (208) 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 /> ❑SCiL BORING# [ROVER-BORE DIAMETER <br /> ❑WELL# Q PRESSURE GROUT <br /> ❑`OTHER GROUT SPECIFICATIONS <br /> Pressure grout one 65 foot monitoring well 04;1-3) <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 34') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES @st 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,anff I applicable allf9mla Laws. <br /> Signed /I �i✓vuc .� Title/Company STAFF SCIENTIST/ADVANCED GEOENVIRONMENTAL INC <br /> Print Name T',,�AE_11k_ (:sir,'�td c(J Date 4%� <br /> DEPARTMENT USnE-`ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �� <br /> WORK PLAN DATED: e C_t 7 Z&O,�' r Q rte.--- 1-3 (A.` �' �� LU1��� <br /> APPLICATION ACCEPTED BY DATE ISSUED �Q O a AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY f-Q DATE 10124, 0 <br /> COMMENTS/CONDITIONS: e lJ!/Z1--19 CA LtA,,�C 5 <br /> 97, <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D B1 D ATE PERMIT/SERVICE# I INVOICE <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZ,IT10', MIT ENCROACHMENT DOC <br /> EHD 29.01 11/5/07(WEB) WELL PERMIT AFP <br />