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LF) I / IISII"' l rt-7''��- <br />SAN JOAQUIN COUNTY <br />—.. a Jf`! s 95"RONMENTAL HEALTH DEPARTMENT <br />CA 95202-3029 SITE <br />ENV � �,�_ IPoo t Main Street Stockton, M� Q� <br />' 8-3449 Fax. (209) 468-3433 Web, www.sjgov.orq/ehd NT <br />%FOR1i •=- � �v <br />WELL PERMIT APPLICATION JUN 3 0 2009 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN J <br />OAQUIN0U_ TY <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in�ithj6l� i <br />Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. H DEPARTMIfW <br />Assessor's <br />Well Location 7650 S. Newcastle Rd Cross Street Arch Road City Stockton Zip 95213 Parcel # 181-15-2 <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 6361053 , Y 2147828 _Township 1 North Range 7 East Section 34 <br />WORK TO BE PERFORMED: <br />AID # <br />® NEW WELUBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ SOIL BORING# <br />❑ OVER -BORE DIAMETER <br />® WELL # AMW-22S <br />❑ PRESSURE GROUT <br />❑ *OTHER <br />GROUT SPECIFICATIONS <br />COMMENTS: <br />1 Cb <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 IX1 MUD ROTARY <br />DEPTH OF GROUT SEAL 0-71 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 4 x 94# Portland cement + max. 5% bentonite + 100 gal water <br />❑ OTHER: ❑ OTHER: <br />APPROX. BORING DEPTH 97 feet ❑ BOLTED TRAFFIC BOX OR M 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 pr pared his application and <br />that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and I is a l' ornia ws. <br />Signed <br />Title/Company Manager -Remedial Services/Herst & Associates, Inc. <br />Print Name William J. Piernathy <br />Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY DATE ISSUED <br />GROUT INSPECTION BY FINAL INSPECTION BY <br />DESTRUCTION INSPECTIO DATE <br />COMMENTS/CONDITIONS: <br />DATE <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 # INVOICE <br />1 Cb <br />c <br />SR d <br />C-57 ' WC <br />EHD 29-01 11/5/07 (WEB) <br />-WAIVER C57 LETTER OF AUIHORIZAI ION TO SIGN PIERMIT ENCROACHMEN I UUC <br />WELL PERMIT APP <br />