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o <br /> CSan Joaquin Coun <br /> �A Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-,i is L MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: .sjgov.or&hd � <br /> � - -:UNIT IV <br /> Well Permit Applicati nN <br /> _.. �f <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described.`,_Thit'application islrnade tri compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental:Health;Departm2nt <br /> Assessors <br /> WELL Location 2850 Loomis Rd. Cross Street Mariposa Rd.City Stockton Zip 95205 Parcel#179-100-03 <br /> PROPERTYp� Qj+ GId^r1Pi(S�! �f)'"��� G C'arLC cJpSC "" `�a <br /> Owner V-i-neLand—Gonstr-uet- c- <br /> on— o-. Address 71 West Park Ave CityV'n.1.nd xa ip08360 Phone# <br /> e� r <br /> C-57Contractor cascade Drillin3, inc. Address 3652 oman <br /> ac Circle Cit cho cordovaZip Lie# �'�� � Phone# <br /> Consultant/Sub Cntr Advanced GecEnvironmental Address 837 Shaw Rd City Stockton Lic# �'S 0.2.2/'hone# �?O <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPU - N - UGER, p DESTRUCTION (choose type below) <br /> $SOIL BORING# B-2 ©OVER-BORE. DIAMETER <br /> $WELL# MW-6 ©PRESSURE GROUT <br /> F C <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> $MONITORING $HOLLOW STEM DIA.OF BOREHOLES.25" MULTI PLECASINGS 0 MULTI-LEVEL WELL CASING DIA:—2..D" <br /> D EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL D PVC BOTHER: Blank <br /> n VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 120' 15C' TREMIE TYPE TO BE USED: 0 AUGERS $HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> B SOIL BORING ll HAND AUGER GROUT SPECIFICATIONS T e I/II Portland neat cement <br /> a OTHER: a OTHER APPROX.BORING DEPTH 13 and 350' $BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROP6�6 F-"-;o <br /> s-;a-7 (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIR D FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that thework will be done in accordance with San Joaquin <br /> County Ordinan Ids and Regulations, and all applicable California State Laws. <br /> : '` <br /> • j ��v.r� ��CrL�Yc ti�-/Acl1,�."tv��rcf��U�YZi�tcSs�men•lz:f Tom:. <br /> Signed xTitle/Compsy Vice President/ Advanced GeoEnvironmental, Inc. / <br /> Print Name Robert Marty IUCIL. 0 Date 30 April 2007 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: L9 5-0 L oo yn v ad, (—' <br /> WORK PLAN DATED: Z 0 D 1 <br /> � M,-,(4a , dI <br /> Application Accepted By V 1 c,+r,r. -,t L Y`-Tn P-N/ Dae Issued M 6 �! 3 2/04 � Area �"T <br /> Grout Inspection By 1���� ,^d 4r �Gcr! �i Date ��ct 15L/07 Final In pection By VL' : G r ;�tE!Date Jam—/ u`7 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: ri r.o ayz r e -� o f n 4 11,i ,,5n /( �A/ ` <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT'REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 'x503 �--, 6.5 . �3 0? SR# (,Q Oar l <br /> C-57 WC -WAIVER— C-57 Letter of Authorization to ign permit—Encroachment doc_ <br /> EHD 29-02-001 <br /> 6122104 <br />