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A` "'" • SAN JOAQUIN COUNTY <br />l�� I' ')ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />c+s i} T�ephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br />q<ikoRN� jum S !i <br />SITE <br />W <br />EN�IR(�1'�f:1E�,I,t ;-i`At-TH WELL PERMIT APPLICATION <br />PER"u":i i/ c 11.1. <br />N;N-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SUN 3 0 2009 <br />SAN JJp�f .. <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is mad <br />Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. HEALTH DEPARTMENT' <br />Assessor's <br />Well Location 7650 S. Newcastle Rd Cross Street Arch Road City Stockton Zip 95213 Parcel # 181-10-7 <br />Property <br />Owner CA Dept of Juvenile Justice Address 7650 S. Newcastle Rd City Stockton Zip 95213 Phone # 209-944-6327 <br />C-57 Contractor Precision Sampling, Inc. Address 2365 Wigwam Drive City Stockton Lic# 636387 Phone 209-465-8712 <br />Consultant/Sub Cntr Herst & Associates Address4630 S. Hwy 94-N. Outer Road City St. Charles, MO Lic # Phone 636-939-9111 <br />GIS Coordinates: X 6364220 'y 2150276 —,Township 1 North Range 7 East Section 27 <br />WORK TO BE PERFORMED: <br />® NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ SOIL BORING# ❑ OVER -BORE DIAMETER <br />® WELL # AMW-24 ❑ PRESSURE GROUT <br />❑ *OTHER GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />❑X MONITORING ❑ HOLLOW STEM <br />DIA. OF BOREHOLE 8 inch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 2 Inch <br />❑ EXTRACTION ❑ AIR HAMMER/DRIVEN <br />CASING THICKNESS SCh 80 TYPE OF CASING: ❑ STEEL ® PVC ❑ OTHER <br />❑ VAPOR 5d MUD ROTARY <br />DEPTH OF GROUT SEAL 0-124 ft TREMIE TYPE TO BE USED ❑ AUGERS ® HOSE <br />❑ AIR SPARGE/OZONE ❑ PUSH POINT (GP OR CPT)_ <br />GROUT SEAL PUMPED: ® Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />❑ SOIL BORING ❑ HAND AUGER <br />GROUT SPECIFICATIONS 6 X 94# Portland Cement + max. 5% bentonite + 100 gal water <br />❑ OTHER: ❑ OTHER: <br />APPROX. BORING DEPTH 150 feet ❑ BOLTED TRAFFIC BOX OR ® STOVE PIPE <br />l0/1 �� <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <br />SR#5-7 7 0- <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />I hereby certify that I h pr pared t appiption and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all is e C ' nia L <br />Signed' <br />Title/Company Manager -Remedial Services/Herst & Associates, Inc. <br />Print Name William J. kernathy <br />Date 7 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY <br />DATE ISSUED AREA <br />GROUT INSPECTION BY _ <br />FINAL INSPECTION BY DATE <br />DESTRUCTION INSPECT16 ZY <br />DATE <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />PERMITISERVICE # <br />INVOICE <br />l0/1 �� <br />�� <br />g'a a <br />SR#5-7 7 0- <br />C-57 WC <br />EHD 29-01 11/5/07 (WEB) <br />-WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />WELL PERMIT APP <br />