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L LL <br />pgb!!N� JJhI I i ?.009 • SAN JOAQUIN COUNTY <br />041 -EN T !- EAU �i ENVIRONMENTAL HEALTH DEPARTMENT SITE <br />IQ; fJlil,SERVI CE"`:, 600 East Main Street, Stockton, CA 95202-3029 <br />MITIGATION <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd PgtMEW„ <br />9�iFOR`� <br />WELL PERMIT APPLICATION <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 d��{ 11�1h �n <br />Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health DepartmentHE NMENTAL <br />Ass'jftWAR1TM� <br />Well Location 7898 S. Austin Road Cross Street Burnham Road City Stockton Zip 95215 Parcel # 18 - ►8- <br />Property <br />Owner Sukhwinder Johal Address PO Box 31063 City Stockton Zip 95213 Phone # <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 6364905 , Y 2148936 Township 1 North Range 7 East Section 35 <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-18B ❑ 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 Rl 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 El 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 />8 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />thereby certify that I (Cap <br />repared t appli ation and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and le C nia La <br />Signed Title/Company Manager -Remedial Service//s/H rst & Associates, Inc. <br />Print Name William J. kernathy Date /o 17 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY DATE ISSUED L AREA <br />GROUT INSPECTION BY FINAL INSPECTION BY DATE <br />DESTRUCTION INSPECTIOW/_ 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 />('° <br />�`i <br />\\o ✓Lp <br />i <br />SR#. <br />C-57 - WC ` -WAIVER <br />EHD 29-01 11/5/07 (WEB) <br />Cb/ Lt I I EK UI- AU I HUKILA I IUN I U 616NI-LWI I ENCKUAGHMEN I UUG <br />WELL PERMIT APP <br />