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,oP"u17 �o SAN JOAQUIN COUNTY . <br /> �����WRONMENTAL HEALTH DEPARTMENT SITE <br /> y 600 East Main Street, Stocktoh , CA 95202-3029 MITIGATION <br /> NUVTq/eViM (209) 468-3454 Fax: (209) 468-3433 Web: www.sigoy.org/ehd UNIT IV <br /> crFbR 1 <br /> ENVIRONMENT HEAMELL PERMIT APPLICATION <br /> PEEtMITISt M=NDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> 6 V O Assessors <br /> Well Location'�''�''e' PACIFIC AVE Cross Street PORTER AVE City STOCKTON Zip 95207 parcel # 081 - 360 - 03 <br /> Properly STEVEN CANEPA 1536 N . HUNTER ST STOCKTON 95204 209 - 948 - 1636 <br /> Owner Address City Zip Phone # <br /> ADVANCED <br /> C47 Contractor GEDRNVTRnmmRNTAi Address 837 SHAW ROAD City STOCKTON Zip 95215 Lic # 680227 Phone <br /> ADVANCED GEOENVIRONMENTAL 837 SHAW ROAD STOCKTON 95215 209 - 467 - 1006 <br /> Consultant/Sub Cntr Address City Lic # Phone <br /> GIS Coordinates: X , Y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> [3 NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') E] DESTRUCTION (CHOOSE TYPE BELOW) <br /> Ea SOILBORING# V- 1 , V- 2 , V- 3 , V- 4 , V- 5 , V- 6 <br /> El OVER-BORE DIAMETER - <br /> ❑ WELL # ❑ PRESSURE GROUT <br /> ❑ `OTHER GROUT SPECIFICATIONS <br /> ❑ EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE 1 , 5 " ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELLCASING DIA: _ (v <br /> ❑ EXTRACTION ❑ AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER t <br /> ❑ VAPOR- El MUD ROTARY - - DEPTH OF GROUT SEAL. SFC TO TO TREMIE.TYPE TOBEUSED. ❑ AUGERS p-HOSE <br /> ❑ AIR SPARGE/OZONE IN PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: ❑ Yes ❑ No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) (((111 <br /> CaSOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS PORTLAND NEAT CEMENT TYPE I/ II <br /> ❑ OTHER ❑ OTHER: CONDUCT BORING DEPTH <br /> 5 FT AND 30 Fb BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br /> CONDUCTOR WHILE <br /> CASINGPROPOSED (PYEs,.lX spetlfieatiens In mmment section) <br /> COMMENTS: V- 1 THAU V- 5 TO BE ADVANCED TO 5 FT , WHILE V- 6 TO BEVANCED T�APPROX 30 FT <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENTPERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br /> Regulations, a ' -all a Iicabl Ilfornia.Laws- <br /> Signed Title/Company ADVANCED GEOENVIRONMENTAL , INC <br /> Print Name RO 'ERT MARTY Date 09 NOVEMBER 2009 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: p (0230 / 4tr4YrC ,7 w-� S*� k �W <br /> WORK PLAN DATED:Wcy/ 1��9 <br /> APPLICATION ACCEPTED BY Itle 7' DAT ISSUED �� �.Q 09 AREA �y <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE Y t <br /> DESTRUCTION INSPECTION BY DATE <br /> ' COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID # FAC # <br /> PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE PERMIT/SERVICE # INVOICE <br /> Wo <br /> / ?N �/3`/ 30337 SR# 00 58763 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29.01 10/28/09 - WELL PERMIT APP <br />