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P°`"t" • SAN JOAQUIN COUNTY <br />N Cr f �j"r-'ENVIRONMENTAL HEALTH DEPARTMENT SITE <br />500 East Main Street, Stockton, CA 95202-3029 MITIGATION <br />.iij�1 Ze(�p�pne: (209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.orct/ NIT IV <br />lv7E <br />ENV1f�UPvi4)cI�T ; l�ALI H <br />WELL PERMIT APPLICATION RECEIVED <br />PERkil l' Rt/i�it &-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JUN3 p ��q <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is mad In compliance wit�ali <br />Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. V'AN JOAQ <br />wi&oU1N COUNTY <br />Well Location 7650 S. Newcastle Rd Cross Street Arch Road City Stockton Zip 95213 P H - -PL <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 />ConsultantlSub Cntr Herst & Associates Address4630 S. Hwy 94-N. Outer Road City St. Charles, MO Lie # <br />GIS Coordinates: X 6359082 <br />,Y 2152280 <br />,Township 1 North <br />WORK TO BE PERFORMED: <br />® NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />❑ SOIL BORING# <br />® WELL# AMW-27 <br />❑ *OTHER <br />COMMENTS <br />Phone 636-939-9111 <br />Range 7 East Section 27 <br />❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ OVER -BORE DIAMETER <br />❑ PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑X MONITORING <br />❑ HOLLOW STEM DIA. OF BOREHOLE 8 inch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 2 Inch <br />❑ EXTRACTION <br />❑ AIR HAMMER/DRIVEN CASING THICKNESS SCh 80 TYPE OF CASING: ❑ STEEL ® PVC ❑ OTHER <br />❑ VAPOR <br />® MUD ROTARY DEPTH OF GROUT SEAL 0-124 ft TREMIE TYPE TO BE USED ❑ AUGERS ® HOSE <br />❑ AIR SPARGE/OZONE <br />❑ PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: ® Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />❑ SOIL BORING <br />❑ HAND AUGER GROUT SPECIFICATIONS 6 X 94# Portland cement + max. 5% bentonite + 100 gal Water <br />❑ OTHER: <br />❑ OTHER: APPROX. BORING DEPTH 150 feet ❑ BOLTED TRAFFIC BOX OR ® STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <br />SR# 5771 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />I hereby certify that I hav p <br />ared this plication and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all ap <br />I all f Laws. <br />Signed <br />Title/Company Manager -Remedial Servicees/Herst & Associates, Inc. <br />Print Name William J. AbAnathy <br />ZZ Date 7 O� <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY DATE ISSUED AREA <br />GROUT INSPECTION BY <br />FINAL INSPECTION BY DATE <br />DESTRUCTION INSPECTION <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 />PERMIT/SERVICE # <br />INVOICE <br />OD <br />SR# 5771 <br />C-57 WC <br />EHD 29-01 11/5/07 (WEB) <br />-WAIVER C57 LETTER OF AUTHORIZATION TO SIGNLPERMIT ENCROACHMENT DOC <br />WELL PERMIT APP <br />