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eau„� San Joaquin County <br /> Envi iri<lrnental Health Department _,�.��`� g SITE <br /> �� nG ' <br /> 600 E.Main Street, Stockton, CA 95202-3029 �Y <br /> "r- <br /> MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/eII6 =` ,GOO' UNIT IV <br /> err-c�t?� Well Permit Application <br /> sA�'• �Rc��y” � r4^ <br /> pp A'DFppF! <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDY01_1 I <br /> 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 <br /> Joaquin County Development <br /> ev lopmeTATE t Title <br /> Ch RNI11 5.3 and the Standards of San Joaquin County Environmental Health Department, <br /> MILGEO AVE RIPON Assessor <br /> DEPARTMENT OF TRANS PORTATIo <br /> WELL Location rocs Street City Zip 95366 parcel# fA �y�2y <br /> PROPERTYSTATE OF CALIFORNIA <br /> Owner DEPT OF TRANS PORTAT ION Address PO BOX 2048 City STOCKTON Zip 95201 Phone#209-948-3656 <br /> ALL WELL ABANDONMENT 3809 PLEASANT VALLY RD PLACERVILLE 95667 848359 800-948-1355 <br /> C-57 Contractor � c Address City Zip Lic# Phone# <br /> ConsultantlSubcnCrED GEO ENVIRONMENTAL Address CitSHAW ROAD City TOCKTON Li ct611217 phone# 209-467-1006 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL! BORING (CPT,GEOP ROSE, HYDRO PUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> U SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# MW-10 0 PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )DUONITORING HOLLOW STEM DIA.OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:?�__ <br /> 0 EXTRACTION 0 AIR HAMMERfDRIVEN CASING THICKNESS SCHED 40 TYPE OF CASING: Q STEEL B�PVC 0 OTHER; <br /> i 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 11' TREMIE TYPE TO BE USED: ffAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED'. -VYes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS TYPE II NEAT CEMENT (PORTLAND) <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 30' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO' (if YES, list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the Work will be done in accordance with San Joaquin <br /> County Ord' a�,iRulestd Regulations, and all applicable California State Laws. <br /> Signed x (i Title/Company ADVANCED GEOENVIRONMENTAL, INC <br /> Print Name ARTHUR DEICKE Date 10 APRIL 2008 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: S d nom.. <br /> WORK PLAN DATED: aA 07 Z v o <br /> Application Accepted 13 ^"'r`-" Dale Issued P,Se <br /> Grout Inspection By Date 'f Fina]Inspection By4A bate "� 66 <br /> Destruction Inspection By Date <br /> COMMENTS l CONDITIONS: A G•!). <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> )-73 8T /41LS- SR# D rgrs <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 web- N <br /> 622/,t h <br />