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SAN JOAQUIN COUNTY <br /> 2 A EN.i'IONMENTAL HEALTH DEPART NT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> fFO� <br /> : (209)468-3449 Fax:(209) 468-3433 Web:www.sigov,orcilehd UNIT IV <br /> 2 3 20x9 WELL PERMIT APPLICATION <br /> OCT <br /> EFUNDASLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> l LNC N <br /> ib This application is made in compliance with San <br /> Application is her ��c t 9ounty for a permit to construct and/or install the work described, pp P <br /> Joaquin County Dev per -9115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor's <br /> Well Location 1648 Shaw Road Cross Street Fremont City Stockton Zip 95215 Parcel# 143-260-15 <br /> Property <br /> Owner—T M G L PARTNERS LP Address 6507 PACIFIC AVE #134 City STOCKTON Zip 95207 Phone# 209-957-4852 <br /> C-57 Contractor ALL WELT, ARANDONMEWT Address 6626 Merchandise way City Diamond Springs II11848359 Phone 530-644-1609 <br /> Advanced GeoEnvironmental <br /> ConsultanVSubCntr Address 837 Shaw Road City Stockton Lic# 680227 Phone 209-467-1006 <br /> GIS Coordinates:X 'y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) R9 DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# X❑OVER-BORE DIAMETER 8" <br /> ❑WELL# IX1 PRESSURE GROUT 551 bsg <br /> ❑"OTHER GROUT SPECIFICATIONS Port nd T eI II <br /> COMMENTS: Pressure Grout three 55' Dual Com letio Wells Mw VW1 MW VW2 MW VW3 •R-r�iot four 60' Wells <br /> (MW4 5 6 7) four 70' Wells (MW9 10 11 12) • and ^P' Iotz one 95' Well (MW8) <br /> l x7>v7l a tI LAW �/�eti7Vw4S[1 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS l� <br /> ❑MONITORING ❑HOLLOW STEM DIA,Or BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMERlDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑ No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> ❑SOIL BORING ❑HANDAUGER GROUT SPECIFICATIONS <br /> ❑OTHER; ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑,STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> - NOT-E:OFFS ITE-BORINGS-REQUIRE-ACCESS-AGREEMENT-OR-ENIGROACHMENT­PERMITS <br /> 48 WORKING HOURS NOTICE= REQUIRED FOR INSPECTIONS <br /> I hereby certify ttA I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, II a tic lifornia Laws.,- <br /> Signed Title/Company Vice _President/Advanced GeoEnvi;.ronmental <br /> Print Name / Ro ert Marty Date 16 October 2009 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: -COPYFILE <br /> WORK PLAN DATED: AJA <br /> APPLICATION ACCEPTED BY at+-- DATE ISSUED /017,3/0AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BYDATE I� <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: r <br /> ACCOUNTING ONLY: AID# FAC# 3 <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE l <br /> SR# 59&32- <br /> C-57_WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT r . ENCROACHMENT DOC <br /> EHD 29-01 4115147(WEB) - WELL PERMIT APP <br />