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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />tJt� 2009 SITE <br />600 East Main Street, Stockton, CA 95202-3029 REW�" tPN <br />�.. .,..P T �e e: (209) 468-3449 Fax: (209) 468-3433 Web: www.siqoy.om/ehd <br />o a <br />VII{; Cv�1Ei`1T;j�gWf CUNtTL4jb <br />PE !�iT�`�VI"ES WELL PERMIT APPLICATION JUN 3 0 2009 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN COUNTY <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is nENr11Y '1Mft1 San <br />Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. �MENT <br />Assessor's <br />Well Location 7650 S. Newcastle Rd Cross Street Arch Road City Stockton Zip 95213 Parcel # 181-15-11 <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 6362728 Y 2148924 , 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-23S ❑ PRESSURE GROUT <br />❑ *OTHER GROUT SPECIFICATIONS <br />COMMENTS: <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 RI PVC ❑ OTHER <br />❑ VAPOR RI MUD ROTARY <br />DEPTH OF GROUT SEAL 0-64 ft TREMIE TYPE TO BE USED ❑ AUGERS ® HOSE <br />❑ AIR SPARGE/OZONE ❑ PUSH POINT (GP OR CPT)_ <br />GROUT SEAL PUMPED: I@ Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />❑ SOIL BORING ❑ HAND AUGER <br />GROUT SPECIFICATIONS 3 x 94# Portland cement + max. 5% bentonite + 100 gal water <br />❑ OTHER: ❑ OTHER: <br />APPROX. BORING DEPTH 90 feet ❑ BOLTED TRAFFIC BOX OR ® STOVE PIPE <br />�o b <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <br />S R#.� <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />I hereby certify that I h4ve re ared thi application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all ab Cal ria Law . <br />Signed <br />Title/Company Manager -Remedial Servicers/Herst & Associates, Inc. <br />Print Name William J. A math <br />Date 6 �7 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY C�-S <br />DATE ISSUED -7 , AREAz� C <br />GROUT INSPECTION BY <br />FINAL INSPECTION BY DATE <br />DESTRUCTION INSPECTION Y <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 />Cl v <br />�o b <br />3© ,0e) <br />S R#.� <br />C-57 WC <br />EHD 29-01 11/5/07 (WEB) <br />-WAIVER G57 LETTER OF AU I HORILAI IUN I U SIGN PERMIT ENGROAGHMEN I UUG <br />WELL PERMIT APP <br />