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SAN JOAQUIN COUNTY * FILE COPY <br /> <� ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 I7 TION <br /> 16 Q Telephone:(209)468-3449 Fax: (209)468-3433 Web:www.s' o . CaW IV <br /> IU�1 WELL PERMIT APPLICATION MAY 1 1 2009 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE iss&WRONMENT <br /> '/H(E�ALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicatonMisT(§0if��C 91iance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Well Location 14749 N THORNTON RD Cross Street CAPITOL AVE ASS <br /> Property City Lonl Zip 95242 parcel cel# oss-l5o-z6 <br /> Owner PADILLA, MILA S Address PO BOX 1036 City TRACY Zip 95378 Phone# (209)832-7780 <br /> C-57 Contractor ADVANCED GEOENVIROWENTAL Address 837 SHAW ROAD L`gy STDC"ON Zip 95215 LIC# 680227 Phone <br /> Consultant/Sub Cntr SAME AS ABOVE Address ap City Lic# Phone (209)467-1006 <br /> GIS Coordinates:X e• 113 'Y --I�• / [ ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> EI NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> ® SOIL BORING# S-3 & S-4 F S-5 ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1.25" 0 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: NA <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER NA <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 10' bsg TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE IN PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED: [ Yes [N No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ®SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS PORTLAND TYPE II <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 10'bscr ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (AYES,list speOicetions In comment section) <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,"I ap Icab a forma Laws. <br /> Signed Title/Company VICE PRESIDENT <br /> Print Name ROBEky MARTY Date 05/08/09 <br /> DEPARTMENT USE ONLY J�6 AAW• :W; <br /> Zl'J�D rr / 9 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: N-WORK PLAN DATED: 4- 7�- qd/ <br /> APPLICATION ACCEPTED BY DATE ISSUED 2/ Q AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY ^ DATE <br /> COMMENTS/CONDITIONS: 09 IC <br /> ACCOUNTING ONLY: AID# FAC# - <br /> PE CODES FEE INFO AMT REMITTED CHECK# R CV'D B DAT PERMITISERVICE# INVOICE <br /> C-57 V WC -WAIVER C57 LETTER OF AUTHORIZf(IC IGN D ENCROACHMENT DOC- <br /> EHD2MI 11/5/07 L U <br /> WELL PERMIT APP <br />