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i§ <br /> agD1H SAN JOAQUIN COUNTY <br /> ENVRONMENTAL HEALTH DEPARTM T SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> " � •Tel'ephone:(209) 468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> \4.occV coR <br /> AVN P��Nkct <br /> Sp1�3N WELL PERMIT APPLICATION C (� <br /> e7Pp' { <br /> �y(N NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED V <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. Assessor's <br /> Well Location 1601 Turnpike Road Cross Street S.Lincoin St. City Stockton Zip 95206 Parcel# 165-040-13 <br /> PropertyEOX 6569 Gj( STOCKTON Zip 95206 Phone# 209-993-4432 <br /> PC Owner LOPEZ NEREIDA P Address y <br /> C-57 Contractor Advanced Geoenv menta! Address 887 Shaw Road City Stockton Zip 95211 Lic# 680227 Phone <br /> ConsultanUSub Cntr same as above Address City Lic# Phone <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> M NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑❑DESTROVER-UCTION <br /> ORE (CHOOSE <br /> TYPE BELOW) <br /> ® SOIL BORING# BST-1 E:1ER <br /> PRESSURE GROUT <br /> El WELL# <br /> E]*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2 n ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 65' bs9 TREMIE TYPE TO BE USED®AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE El PUSH POINT(GP OR CPT) GP GROUT SEAL PUMPED.®Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ®SOIL BORING ❑ HANDAUGER GROUT SPECIFICATIONS Portland Type II — <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 65' ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE <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 certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable Calif is Laws. <br /> Signed (i/{�//� (/ ITill¢/Company Project Scientist/Advanced GeoEnvironmental <br /> Print Name Ally Colavita Date 06/15/10 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I 1 I f/Y,ri P, !` l� D n <br /> —1 <br /> WORK PLAN DATED: 1 <br /> APPLICATION ACCEPTED BY `/ I L I D f tt AQ� DATE <br /> �/ISSUED �o /O AREA t4�9 <br /> GROUT INSPECTION BYyl bh r ig m lP"tnoi� FINAL INSPECTION BY V i/ n6'a Y/�C/6�fh�c. DATE 4 -14 <br /> DESTRUCTION INSPECTION BY r p DATE <br /> COMMENTSICONDITIONS: Al ynber;rt,A 05T- 1 46 /2�%j",a T bs� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE if INVOICE <br /> 356 a s:°oo 434.00 31200 L(fyJL GIG !o SR# OpG02� <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PER IT ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> EMD 29-01 11/5/07 <br />