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PgUlry y ,4•�_ �..o SAN .IOAQUIN COUNTY \9 � w % ENVIRONMENTAL HEALTH DEPARTMENT k%��,1P� r►+F'" E 600 East Main Street, Stockton, CA 95202-3029 �F3`" V MITIGATION Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sioov.orcl/e( UNIT IV 4fFOR WELL PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. Well Location 4075 E.Main St Cross Street Oro City Stockton CA Zip 95215-6726 parcel#rs.zea„ Property Owner or.Jay mclo-em Address 4075E.Main St City Stockton CA Zip 95215-6726 Phone# (209)464-8707 C-57 Contractor Precision Sampling Inc(PSI) Address 2365 Wigwam Dr. City Sto&ton CA Zip 95205 LIC# 636387 Phone Consultant/Sub Cntr ATC Associates Address 1117 Lone Palm Ave.Suite 201 City Modesto,CA Lit# Phone(209)579-2221 GIS Coordinates:X 37.954100 Y -121.234603 ,Township T1N Range WE Section Sec` WORK TO BE PERFORMED: E NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) ❑SOIL BORING# ❑OVER-BORE DIAMETER E WELL# MW12a05nbg.l.MWlc(IIM gs).MW3colonbgp. ❑PRESSURE GROUT ❑N 'OTHER GROUT SPECIFICATIONS ❑EXPLOSIVES DETONATING CARD COMMENTS:See ATC WkPlrs Supplemental Subsurface Investigation Work Plan dated 2/272009 and Interim Remediation Implementation Work Plan dated 3/512009 approved by Lod Duncan TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Birch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS PVC Schd 40 TYPE OF CASING:❑STEEL ]PVC ❑ OTHER None ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS O HOSE 9 AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:9 Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') ❑SOIL BORING NHAND AUGER Hand clear to No feel GROUT SPECIFICATIONS Neatcement ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE aaada b. CONDUCTOR CASING PROPOSED x. (it YES,list specifications in comment section) - COMMENTS:mn„g.ad b.aa.:er.au canam. ..smlc.adwd�.rrow..lmaitlr rs.m,mi..,bs.no..w... .1131MIam er mo am dtlMdW Wrmd.a..a be kwrw. 7.l appmuraly�saiZi 11D 1e.16m ele�ll®Lw,. NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS 1 hereby certify that I have pr red this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and Regulati ns,Nd all a lica le lif 'a L ws. F / .10011111. Signs t' % Title/Company ATCAssociates Print Name Michael D.Sonke Date ry 18, DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: y0� /,O6Y/N s4tze/" WORK PLAN DATED: L/Z-VOI 1214 /( 31j! 09 APPLICATION ACCEPTED BY Wd, "v DATE ISSUED 3 L y / AREA GROUT INSPECTION BY 116 FINAL INSPECTION BY �MDATE Z I 1 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE 3SU3 cy3yr00 1 065'632 17,/74111/0 SR# sgSgl C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 10/28/09 WELL PERMIT APP J