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o.�q''''�•.c SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 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 /> q<<FORa <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 /> Assessor's <br /> Well Location 7650 S.Newcastle Road Cross Street Arch Road City Stockton Zip 95213 Parcel# 181-150-11 <br /> Property <br /> Owner CA Dept.of Juvenile Justice Address 7650 S.Newcastle Road City Stockton Zip 95213 Phone# 209-944-6351 <br /> 209-465-6712 <br /> C-57 Contractor Precision Sampling,Inc. Address 2365 Wigwam Drive City Stockton Zip 95213 LIC# 636387 Phone <br /> Consultant/Sub Cntr Herst&Associate,Inc. Address 4631 North St.Peters Parkway City Saint Charles LIC# Phone 636-939-9111 <br /> GIS Coordinates:X 6362759.26 Y 2148934.21 ,Township 1 North Range 7 East Section 34 <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) iNI DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# i]OVER-BORE DIAMETER elnch(top 5 fl) <br /> g]WELL# AMW-23S PRESSURE GROUT <br /> ❑*OTHER 1 GROUT SPECIFICATIONS NEATcement <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS:Monitoring well AMW-23S is located in the construction zone of the proposed California Health Care Facility and requires abandonment. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑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 TREMIE TYPE TO BE USED❑AUGERS El HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <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 California Laws. <br /> Signed /-a Or CAn n Title/Company Staff Biologist/Herst&Associates,Inc. <br /> Print Name Erin Fanning Date March 2,2011 PAYMFNT <br /> DEPARTMENT USE ONLY MAR <br /> SITE MAP IN UNIT IV FILE,ADDRESS: MAR _9 2011 <br /> SAN JOAQUIN COUNTY <br /> WORK PLAN DATED: AL <br /> APPLICATION ACCEPTED BY ` HEALTH DEPARTMENT <br /> V�hCS�+,9-�— DATE ISSUED q AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY� : DATE //r/ <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> q J - /dg- jq3jq 2W, 3 f SR# Oti <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />