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~ *San Joaquin County <br /> Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 ��n rgpATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.or V LIJJ�IT IV <br /> aR Well Permit Application DEC 1 8 2009 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS �1�/t�f�Rr;11 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describe .,awe hULNompliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmen i1 V7 9�Q <br /> A�§6essors <br /> WELL Location 1137 South Stockton Street Cross Street Navy Drive City Stockton Zip 95206 Parcel# 163-260-22 <br /> PROPERTY <br /> Owner John & Bonnie Phillips Address 1133 BristolAvenue City Stockton Zip 95204 Phone# (209)944-0909 <br /> C-57Contraclor RSI Drilling Address220 North East Street City Woodland Zip 95776 Ue# 802334 Phone#(530)668-2424 <br /> Advanced <br /> Consultant/Sub Cntr GeoEnvironmental, Inc. Address 837 Shaw Road City Stockton Uc# 680227 Phone# (209)467-1006 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> B NEW WELL/BORING (Ops,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> B SOIL BORING# Bll through B17 0 OVER-BORE. DIAMETER <br /> g WELL# MW-1 through MW-4 aPRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> Reference: AGE-prepared Additional Site Assessment Work Plan, dated 22 September 2009 and <br /> COMMENTS: Additional Site Assessment Work Plan-Addendum, dated 02 November 2009 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> B MONITORING B HOLLOW STEM DIA.OF BOREHOLE"'/8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2" <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL $PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL min. 30'/8'TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> B SOIL BORING aHAND AUGER GROUT SPECIFICATIONS TVDe I/II Portland Neat Cement <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH min. 30' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> ReEerence: AGE-prepared Additional Site Assessment Work Plan, dated 22 September 2009 and <br /> COMMENTS: Add'ti 1 Site <br /> t A t W k P1 -Add d dated 02 No,eb.r 2009 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <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 in accordance with San Joaquin <br /> County Ord! nc Ru nd R gulat' rr Ind all applicable California State Laws. <br /> Signed Title/Company Vice President, Advanced GeoEnvironmental, Inc. <br /> Print Name ober . Marty Date 16 December 2009 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I I ;1 S• Srl t—S f- FILE ■ <br /> nuflyq <br /> WORK PLAN DATED: ,2z 1cel 111/z Io <br /> Application Accepted By Pi—.lti Date Issued )2-12.3�0 `7 Area <br /> Grout Inspection By (&A A16w— Date I L -4-r(!25Final Inspection By Tinn,i�� Date <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 /> 2-101 Y3Y.oe) 30Y30 Air / 2:/0� SR# <br /> C-57_ WC---WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> FHD29-02-001 WEB <br /> 9/11/2007 <br />