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SAN .IOAQUIN COUNTY • <br />. �L� `JI V <br />b4IRONMENTAL HEALTH DEPARTMENT <br />� SITE <br />.� - ��(� 00 East Main Street, Stockton, CA 95202-3029 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Z4_ -ANA <br />41Fog� Yj <br />ENV!ROPjiMENT ;IEALT <br />PERV,!'F,;SERV!CES'WELL PERMIT APPLICATION EIVED <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 ma69ANfrfUNN <br />Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. ENVIRONMENTAL <br />► ar'"qP_q _WN7- <br />Well Location 7650 S. Newcastle Rd Cross Street Arch Road City Stockton Zip 95213 Parcel # <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 Lie# 636387 Phone 209-465-8712 <br />Consultant/Sub Cntr Herst & Associates Address4630 S. Hwy 94-N. Outer Road City St. Charles, MO Lie # Phone 636-939-9111 <br />GIS Coordinates: X 6362968 Y 2152692 -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-25 ❑ PRESSURE GROUT <br />❑ 'OTHER GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />© 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 Rl MUD ROTARY DEPTH OF GROUT SEAL 0-124 ft TREMIE TYPE TO BE USED ❑ AUGERS N1 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 6 X 94# Portland cement + max. 5% bentonite + 100 gal water <br />❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 150 feet ❑ BOLTED TRAFFIC BOX OR 8 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 cert:and <br />that I have ared this plication and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, all a p ' le alifo Laws <br />Signed Title/Company Manager -Remedial Servicees/Herst & Associates, Inc. <br />Print Name William J. Ab ath Date (� e�/ <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY DATE ISSUED 0 AREA <br />GROUT INSPECTION BY FINAL INSPECTION BY DATE <br />DESTRUCTIONINSPECTI Y 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 />PERMIT/SERVICE # <br />INVOICE <br />0 <br />- <br />��'� $ <br />e'YG <br />k <br />SR# 5-110-7 <br />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 />