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aMin Joaquin County <br /> Enviro....nentaly Health Department SITE <br /> 600 East Main Street; Stockton, CA 9 202-3ITIGATION <br /> • (209)468-3449 Fax: (209)468-3433 Web: .sjg0%9ENEC" UNIT IV <br /> Well Permit Application <br /> ii JAN 19 2010 r ILL UUPY <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRO M DATE ISSUED Lt���Cnn��-I-�' <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install thework d IitatrWt tsINJe in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin Co my Envira ? lJW <br /> Algnt. <br /> Loomis Rd. k Assessors <br /> WELL Location <br /> 2850 Loomis Rd. Cross Street Hwy•99 Frontage ity Stockton Zip 95205 Parcel# 179-100-03 <br /> PROPERTY Four R's Partnership <br /> /o Dan Folcher 71 West Park Ave. Vi eland, NJ 08360 855-470-2727 <br /> c <br /> Owner Address City Zip Phone# <br /> A.G.E. 837 Shaw, Itd. Stockton 95215 680227 209-467-1006 <br /> C-57 Contractor Address City Zip Lic# Phone# <br /> Consultant I Sub Cntr A.G.E. Address 837 Shaw Rd. City StocktonLick680227 Phone# 209-467-1006 <br /> �i <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORM?=D: <br /> p NEW WELL 1 BORING -(4GEOPP QBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER ` <br /> []WELL# 0 PRESSURE GROUT t <br /> []*Other GROUT SPECIFICATIONS <br /> COMMENTS: See Vapor Intrusion Work Plan, dated 12 November 2009 [J� <br /> Q <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATI Ms <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2" 0 M LTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: NA <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 5' TREMIE TYPE TO BE USED: 0 AUGERS J&HOSE C, <br /> p AIR SPARGE!OZONE S PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes H No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> &SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Por land Type II <br /> 0 OTHER:_G OTHER APPROX.BORING DEPTH 5` 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOS ED NA (if YES,list specifications in comment section) <br /> COMMENTS: See EHD-approval letter, dated 06 January 2010 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGRE MENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS[NOTICE REQUIR D FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the w rk will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable Calif rnia State Laws. <br /> Signed x <br /> TitlelCompa y Project Manager/A.G.E. <br /> Print Name <br /> Timothy V. Cuellar Date 19 January 2010 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2 8 U Lopmi.­ 20401 <br /> WORK PLAN DATED: ►Z .2 <br /> Application Accepted Byy -tn r; 0- L. M CCa rn ev D to lssued 1 --21 -10 Area _ <br /> Grout Inspection By Vi a Date '9—/ In pection By ' 1 �r.;6 11,T17fe Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: p� <br /> I <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#. REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3s'r� t34.00 x-34.00 30427 �l//9Z !-?1-!U SR# 0OSg205— <br /> LZGo 34S.6o <br /> E C-57 WC---WAIVER C-57 Letter of`Authorization to sign permit Encroachment doc <br /> r FHM?29-02-001 WEB <br /> 9/11/2007 <br />