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in Joaquin County <br /> ,tet c�\ ��' ,L,. <br /> Environmental Health Department L�r��� SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> ` - 209 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> ( > UNIT IV <br /> Well Permit Application EI`dV1'r-4,C' "'or : <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDCfl��'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 Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 3400 Newton Road Assessors <br /> 132-060-08 <br /> WELL Location Cross Street Cherokee City Stockton Zip CA Parel# <br /> PROPERTY bP?it-},TPX,,,,;. j =��. P 0. 13" 93o7 X-110/S/�%s 8 <br /> Owner Mrs. 9 Address 3490-�wZ=ea—Read City Stockton Zip 9520 Phone# (209) 466-3201 <br /> C-57 Contractor all Well abandonment Address 3809 Pleasant valley Road Ci PlacervilleZip95667Lic#848359Phone# (800)948-1355 <br /> Consultant/Sub Cntr advanced GeosnvironmentalAddress 837 Shaw Rd. City Stockton Lic# 680227 0 209-467-1006 <br /> MY <br /> GIS Coordinates:X Y Township Range tne#— <br /> fli <br /> WORK TO BE PERFORMED: <br /> [TNEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# a OVER-BORE. DIAMETER <br /> SWELL# Mw-s, Mw-6, Mw-7, Mw-8 0 PRESSURE GROUT <br /> 0*OtherGROUT SPECIFICATIONS <br /> MW-b througn MW -7 we Ls are monitoring wells (211diameter,51'grout,701total depth) . <br /> COMMENTS: Mw-8 wells are monitoring wells (411diameter,561grout,70'total depth). <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [MONITORING :0HOLLOW STEM DIA.OF BOREHOLE 8-10"0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_2"-4 ' <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS SCH 40 TYPE OF CASING: O STEEL g PVC 0 OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 51' to S6' TREMIE TYPE TO BE USED: O AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0SOIL BORING aHAND AUGER GROUT SPECIFICATIONS Portland Tvoe I/II <br /> OTHER:_0 OTHER APPROX.BORING DEPTH .70' BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 ci�rt�y that I have prjejparecl this application and that the work will be done in accordance with San Joaquin <br /> Cou Ordinances, Rulesrr/i(ndReclulations, and all applicable California State Laws. <br /> Sig edz 6 __�- v- -�� le/Company Staff Geologist/Advanced GeoEnvironmental, Inc. <br /> Print Name Lauren Cardina Date 05/16/oA <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 34 n o New+on `?d <br /> WORK PLAN DATED: ma rch )4-f ZO US <br /> Application Accepted B/y, V)C+DYny G ) �!_h Date Issued 3d O8 Area 40 <br /> Grout Inspection By t 1 LA-&r l fi 1�Pel"/l r —GTr�Date '11� o a Final Inspection By 1�i o r`� ��J��i�i Date_ G —1,7 -;9 g <br /> Destruction Inspection By <br /> 1 Date <br /> COMMENTS/CONDITIONS: 1 - -� L ` f - m�vl Y7? '"77 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3.5-4 89cc 383,00 ? G5 9 -G`�r! �3o1v8 SR# U0�440 ('o <br /> 3ro3 , oa <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to Sign permit x Encroachment doc— <br /> EHD 29-02-001 <br /> 6/22/04 <br />