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0 <br /> o qln. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> e SITE <br /> t 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> a Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> tiFBa <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE 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 /> Asses235 N. Washington Stre Lockeford Lodi 95240 Parcel*Well Location BFoss Street City Zip Parcel# <br /> Property Deborah Cook P. O. Box 9170 Stockton 95208 <br /> Owner Address City Zip Phone# <br /> C-57Contractor Advanced GeoHnvironmmb?W6 837 Shaw Road city Stockton Zip 95215 Lit# 680227 Phone <br /> ConsultantiSub Cntr Same Address Same City Lic# Phone 467-1006 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) [I DESTRUCTION(CHOOSE TYPE BELOW) <br /> []SOIL BORING# B-2 and a-3 ❑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 [I HOLLOW STEM DIA.OF BOREHOLE 2-inchE]MULTIPLE CASINGS❑MULTI-LEVEL WELLCASING DIA:_ <br /> ❑EXTRACTION ❑AIR RAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> []VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 10 feet TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes 19 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ®SOIL BORING ElHAND AUGER 2-inch GROUT SPECIFICATIONS portland cement/slurry <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 10 ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE <br /> COMMENTS: <br /> soil borings only for sampling CONDUCTOR CASING PROPOSED it YES,Int tips fiirsEma in commem sem.) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify th I have�p spared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, II app 4 le-ea11 tis Laws. <br /> VP Advanced GeoBnvironmental, Inc. <br /> Signed Title/Company <br /> Print Name Robert Marty Date 12 July 2010 <br /> Z30 <br /> DEPARTMENT USE ONLY ,I •1� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z30 N' 'Gr—t 5t. �sw <br /> WORK PLAN DATED: 0 f <br /> APPLICATION ACCEPTED BY DATE ISSUED ! Zo Io AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMT REMITTED CHECKS RECV'D BY DATE PERMIT/SERVICES 1 INVOICE <br /> or 1 o SR# ff" <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10128/09 WELL PERMIT APP <br />