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�(- 1 r 1fl <br />• <br />pgD�N l�1i SAN JOAQUIN COUNTY <br />4.•; 1 OG' fC <br />� <br />fIM, 166 � "Oo f-NVIRONMENTAL HEALTH DEPARTMENT SITE <br />600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br />Flylij} O(; Xp"_ 09) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd P, <br />p ''-/fir „— <br />PERVi i/�,.RV!C�S <br />WELL PERMIT APPLICATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JUN 3 0 2009 <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is mad 1 <br />Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. �IEN <br />AHs6sTir sDEPARTMENT <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 6364230 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 />iX1 WELL # AMW-24S ❑ PRESSURE GROUT <br />El *OTHER GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑X MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE 8 Inch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 2 Inch <br />❑ EXTRACTION ❑ AIR HAMMER/DRIVEN CASING THICKNESS SCh 80 TYPE OF CASING: ❑ STEEL ® PVC ❑ OTHER <br />❑ VAPOR ® MUD ROTARY DEPTH OF GROUT SEAL 0-94 ft TREMIE TYPE TO BE USED ❑ AUGERS IXKI HOSE <br />❑ AIR SPARGE/OZONE ❑ PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: M Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />❑ SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS 5 x 94# Portland cement + max. 5% bentonite + 100 gal water <br />❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 120 feet ❑ 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 />I hereby certify that I <br />Regulations, and all <br />Signed <br />Print Name Will <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Title/Company Manager -Remedial Services/Herst & Associates, Inc. <br />Date / <br />DEPARTMENT USE ONLY <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY — C DATE ISSUED AREA <br />GROUT INSPECTION BY _ FINAL INSPECTION BY DATE <br />DESTRUCTION INSPECTION ByDATE <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 />PERMIT/SERVICE # <br />INVOICE <br />SR#'5 a , <br />ta.*illl■��.�c. <br />EHD 29-01 11/5/07 (WEB) <br />-WAIVLK Ub/ Lt I I tK Ur AU I HUKl/A I IUN I U JICiN(F'tHMI I tNUKUAUHMtN I UUU <br />WELL PERMIT APP <br />