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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> pp`C�,vED 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> R" T"one:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> C00,11 WELL PERMIT APPLICATION <br /> JOPNM��-R,f,�NT <br /> 10-�a <br /> C 'vw ANON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <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 345 Yosemite Street Gross Street Lindsay St. City Stockton Zip 95203 Parcel# 135-260-11 <br /> Property <br /> Owner MCDONALD DEVELOPMENT COMPANY INC Address same as above City Zip Phone# (209) 466-2200 <br /> C-57 Contractor ALL WELL ABANDONMENT Address 6626 Merchandise Way City Diamond Springs LIC# 648359 Phone 530-644-1609 <br /> Advanced GeoEnvironmental <br /> ConsultantlSubCntr 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-) ®DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ©OVER-BORE DIAMETER 8" <br /> ❑WELL# ®PRESSURE GROUT 20' bsq <br /> ❑*OTHER GROUT SPECIFICATIONS Portland TypeVII <br /> COMMENTS:_Pressure Grout three single completed ground water monitoring wells (MW2/3/4) ;Drill Out one 20' single <br /> completed ground water monitoring well (Mwl) <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r _� <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: V v <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> 1 <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 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> 5 <br /> ❑OTHER: [71 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 f Ak., Title/Company Senior Project Geologist/Advanced GeoEnvironmental Z <br /> Print Name William Little Date 06/15/2010 <br /> DEPARTMENT USE CONLY, <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: / <br /> APPLICATION ACCEPTED BY Y -f i( DATE ISSUE1&10 AREA M <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY � DATE 7/77/lo <br /> COMMENTSICONDITIONS: L r/lJ J - LAJL j `S S:]k ✓ <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 3 fv� U 6 <br /> Tld-6 G /& co SR#,,,1) v <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> _ <br /> EHb 29-01 11/5107(WEB)�C-�z 1 � 3 v _ ` �� WELL PERMIT APP <br />