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0 0 <br /> ao,.P4 .,o SAN JOAQUIN COUNTY <br /> L` ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> (iccYr� <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 /> Assessorg <br /> Well Location 230 N. Stockton Street Street Lockeford city Lodi Zip 95240 Parcel# 043-085-21 <br /> Properly Deborah Cook P. 0. Box 9170 Stockton 95208 <br /> Owner Address City Zip Phone# <br /> C-57 Contractor Advanced GeoEnvironmmbk6 837 Shaw Road City Stockton Zip 95215 LJc# 680227 Phone <br /> ConsuhanVSub Crdr Same Address Same City Lic# Phone 467-1006 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑x NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> [!]SOIL BORING#3-1 (B-2 and B-3 on separate parcel) ❑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 2-inch D MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/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 Ej No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ®SOIL BORING ElHANDAUGER 2-inch GROUT SPECIFICATIONS Portland cement/slurry <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 10 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: <br /> soil borings only for sampling CONDUCTORCASINGPROPOSED (RYES.list spetlfintions in mmment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify th have �yaredlhis application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,a pl' fe Cal'dorn Laws. <br /> Signed Title/Company VP Advanced GeoEnvironmental, Inc. <br /> Print Name Robert krty Date 12 July 2010 <br /> DEPARTMENT USE ONLY/ �J 1 p <br /> SITE MAP IN UNIT IV FILE,ADD ESS: ��� ���lO _L � Ld�+ FSA, <br /> WORK PLAN DATED: 2m b <br /> APPLICATION ACCEPT B'Y DATE ISSUED 7 aV •I0 AREA <br /> GROUT INSPECTION BY /�'C� �'e-Q FINAL INSPECTION BY ''0 DATE7�l 0 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: '!�SA <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# I INVOICE <br /> 01�-oS 9117- 3l `f N L I 7 Z# is 1 SR#0060RY <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 1028/09 WELL PERMIT APP <br />