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N.. San Joaquin Count <br /> -'': -4 Environmental Health Department SITE <br /> 600 E. Main Street, Stockton, CA 95202-3o WITIGATION <br /> (209)4b8-3449 Fax: (209)468-343:1 Web: www.sjgo <br /> &COVE01 <br /> UNIT IV <br /> Well Permit Application NOV 0 7 2007 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAT M {�{{ nn ��uu <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work des Stgfi'k hl.in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Envir 16i&nt, <br /> 850 MILG80 AVENUE WILMA AVE RIPON 95366 Assessors 261-050-01 <br /> WELL Location Cross Street City Zip Parcel# <br /> PROPERTY <br /> Owner WALTER SHOCKEY Address 117 GOODALE CT City MANTECA Zip95337 Phone#510- <br /> ADVANCED <br /> C-57ContractoPEOENVIRONMENTAL, INAddress 837 SHAW ROAD City STOCKTONZip 95215Lic#680227 Phone# 467-1.006 <br /> ADVANCED <br /> Consultant ISub CntrGEOENVIRONMENTAL, INqAddress B37 SHAW ROAD CttySTOCKTON LIC#680227 phone# 467-1006 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> VNEW WELL/BORING B(C2P3,GEOPRQBE,HYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> o MONITORING a HOLLOW STEM DIA.OF BOREHOLE 2 MULTIPLE CASINGS 8 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: a STEEL la PVC a OTHER: <br /> 0 VAPOR la MUD ROTARY DEPTH OF GROUT SEAL 50' TREMIE TYPE TO BE USED: Q AUGERS 0 HOSE <br /> a AIR SPARGE!OZONE )f PUSH POINT(GP or CPT)GROUT SEAL PUMPED: )gYes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> XII)SOIL BORING a HAND AUGER GROUT SPECIFICATIONS TYPE II NEAT CEMENT (PORTLAND) <br /> a OTHER: o OTHER APPROX.BORING DEPTH 50' Q BOLTED TRAFFIC BOX or 8 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 c that we pr red this application and that the work will be done in accordance with San Joaquin <br /> County din ce , tales Regulations, and all applicable California State Laws. <br /> Signed x Title/Company ADVANCED GROENVIRONMENTAL, INC <br /> Print Name ARTHUR DEICKE Date 05 NOVEMBER 2007 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED,:: � e_-& OL 1, <br /> Application Accepted By E�d�esr1C.�' Date Issued , A Area <br /> Grout Inspection BDate dw,96TFinal Inspection By -Date.//q./Ar <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> ?501 85r 5179 ' �-6S1- e 1=/,to-7 SR#00§�--qos <br /> C-57— WC_ WAIVER C-57 Letter of AuthoriZation to sign permit____Encroachment doc_ <br /> F14D 29-02-001 web <br /> 6122/04 <br /> 503 V <br />