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San Joaquin County <br /> �����VD SITE <br /> Environmental Health Departure <br /> MITIGATION 600 E. Main Street, Stockton,CA 95202-3029 <br /> V91Q 0 7 2007 <br /> ' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.or UNIT IV <br /> VIRONMENT HFA <br /> Well Permit Application EIYCE <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED� �Ti`S� VI� S <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 Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> MILGEO AVENUE F7=IAAA-V-E. RIPON 95366 Assessors <br /> WELL Location IA Re. Cross Street — City Zip Parcel# ' 261-080-23 <br /> PROPERTY MGR LLC 775 FRONTAGE ROAD RIPON 95366 599-4236 <br /> Owner ADVANCED Address City. Zip Phone# <br /> C-57Contracto,GEOENVIRONMENTAL, INRddress 837 SHAW ROAD City STOCKTONZip 95215Lic;#680227 Phone# 467-1006 <br /> ADVANCED <br /> Consultant/Sub CntrGEOENVIRONMENTAL, INCAddress 837 SHAW ROAD CitySTOCKTON Lic#680227 Phone# 467-1006 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> )UMEW WELL/BORING B(CP0; B <br /> GE02PROBE,HYDROPUNCH,HAND-AUGER,OTHER') a DESTRUCTION (choose type below) <br /> )SOIL BORING# 2 a OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> a'Other GROUT SPECIFICATIONS <br /> COMMENTS: �(/t� `� .�-� � r (3ips <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE 2° a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC D OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 40' TREMIE TYPE TO BE USED: D AUGERS a HOSE <br /> D AIR SPARGE/OZONE )PUSH POINT(GP or CPT)GROUT SEAL PUMPED: )4Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> XB]SOIL BORING a HAND AUGER GROUT SPECIFICATIONS TYPE II NEAT CEMENT (PORTLAND) <br /> a OTHER: 11 OTHER APPROX.BORING DEPTH 40' ]]BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (if YES,list specifications in comment section) <br /> COMMENTS: <br /> j <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby cern hat I ha a prep)pf9d this application and that the work will be done in accordance with San Joaquin <br /> County Ord' a S an gulations, and all applicable California State Laws. <br /> Signed x Title/Company ADVANCED GEOENVIRONMENTAL, INC <br /> Print Name ARTHUR DEICKE Date 05 NOVEMBER 2007 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: F5Z' /r,1 '-d i— <br /> WORK PLAN DATED: M e.d Cli<.r <br /> ! ti <br /> Application Accepted By � Date Issued 1_1 r5 c t _—__ Area I_ �� <br /> Grout Inspection ByA[1��p Date rL 677 Final Inspection By Date <br /> Destruction inspection By Date <br /> COMMENTS/CONDITIONS: ar 3 K2. <br /> ACCOUNTING ONLY: AID# VV FAC <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 45.0 1 8q 8"q 00, Z4 s 2 2- talc 1�r�o6 SR#to <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc� <br /> FIID 29-02-001%acb <br /> 6/22/04 <br /> JSP 0- <br />