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FILE COPY <br />San Joaquin County <br />Environmental Health Departmen, <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehUL <br />Well Permit Application <br />SITE <br />05 ?MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDPL <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 compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location 2615 North West Lane Cross Street El Pinal City Stockton Assessors j/F.,070 <br />Zip 9 5 2 0 5 Parcel# <br /> <br />PROPERTY <br />Owner Fabian Ceballos Address 2615 North West Lane City Stockton zip 95205 phone# (209) 474-9465 <br />city Stocktonzip 95215Lic#680227 phone# 209-467-1006 <br /> <br />Advanced GeoEnvironmental <br />C-67 Contractor Address 837 Shaw Road <br /> <br />Advanced GeoEnvironmental <br />Consultant/Sub Cntr Address 837 Shaw Road City Stockton Lic# 680227 <br /> <br />y Phone# 209-467-1006 <br />GIS Coordinates: X ,y 28 , Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />ANEW WELL! BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />liSOIL BORING # GP -1 & GP -2 <br />fl WELL # <br />El *Other <br />COMMENTS: <br />a DESTRUCTION (choose type below) <br />a OVER-BORE. DIAMETER <br />fl PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />El MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 1•125 a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />O EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />O VAPOR 4UD ROTARY DEPTH OF GROUT SEAL Total Depth TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />( <br />OZON <br />a OTHER <br /> GROUT SPECIFICATIONS <br />APPROX. BORING DEPTH < 25 ' <br />6-sack portland slurry <br />(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />40 0:s ILSBPOARRGINEI <br />R P SH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes ff No <br />G HAND AUGER <br />THER: a BOLTED TRAFFIC BOX or a 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 prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinan I and egulations, and all applicable California State Laws. <br />Signed x Title/Company Vice President /Advanced GeoEnvironmental <br />Print Name Robert E. Marty <br /> <br />Date 01-28-2008 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: c 2&16. tel‘•)( itert<- 0 ie— 34 30 14-471/' <br />WORK PLAN DATED: OG <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS! CONDITIONS <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />714 SI3V 617 g 606 <br />131,0 S R#6 .5:3 2.671 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permitN, Encroachment doc <br />EHD 29-02-001 <br />6/22/04 <br />A6LErDate Issued Area <br />Date Final Inspection By Date <br />Date