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�r� ��`�(''� I� %I SAN JOAQUIN COUNTY <br />Pqu(N U <br />? .. .cP\ — <br />?�` ENVIRONMENTAL HEALTH DEPARTMENT <br />:fw�iV iUti I f? <br />20 SITE <br />�l 990 East Main Street, Stockton, CA 95202-3029 MITIGATION <br />+ a •' C���� `rr T}fele��""pp'''ho�i r_�j�j���jjQ91468-3449 Fax: (209) 468-3433 Web: www.sjgov.oMj! d <br />\ t%PORN` EN Iflul'11;. iLNI !.TCr1'� <br />PERMIT/'SERVI"ESWELL PERMIT APPLICATION �VEp <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 ma o gJ h San <br />Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. %g&,@NVIRONMEgL 7Y <br />Epp <br />Well Location 7650 S. Newcastle Rd Cross Street Arch Road City Stockton Zip 95213 Parcel # 1$ P�6WNT <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 6359162 Y 2149330 Township 1 North Range 7 East Section 34 <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-28 ❑ PRESSURE GROUT <br />❑ "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 El PVC ❑ OTHER <br />❑ VAPOR ® MUD ROTARY DEPTH OF GROUT SEAL 0-124 ft 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 6 X 94# Portland Cement + max. 5% bentonite + 100 gal water <br />❑ OTHER: ❑ 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 />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />I hereby certify that I have r ared this plication and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all app le alif . Law <br />Yr <br />Signed - 1ZTitle/Company Manager -Remedial Services/Herst & Associates, Inc. <br />Print Name William J. Ab nath Date % d <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />APPLICATION ACCEPTEDBY' 1. DATE ISSUED AREA <br />GROUT INSPECTION BY FINAL INSPECTION BY DATE <br />DESTRUCTION INSPECTIO Y DATE <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY: AID # FAC # <br />PE CODES <br />FEE INFO AMT REMITTED <br />CHECK # RECV'D BY <br />DATE <br />PERMIT/SERVICE # <br />INVOICE <br />Ig "° <br />6,10 g V�;,- <br />Llwlol <br />SR# 5.7 I i <br />C-57 ' WC <br />EHD 29-01 11/5/07 (WEB) <br />-WAIVER C57 LETTER OF AUTHORIZATION TO SIGNIPERMIT ENCROACHMENT DOC <br />WELL PERMIT APP <br />