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Date <br />.0 r-7 Area / / / <br />Date <br />Date Issued <br />Final Inspection By <br />I -dt.ti (171/ COMMENTS / CONDITIONS: <br />COMMENTS: <br />TYPE OF WELL <br />0 MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />INSTALLATION TYPE <br />0 HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />O MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2.25" U MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: a STEEL 0 PVC 0 OTHER: <br />TREMIE TYPE TO BE USED: fl AUGERS a HOSE <br />0 AIR SPARGE/ OZONE K PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 1:1 Yes )1 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />K SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Cement <br />BOTHER: La Ad- a OTHER APPROX. BORING DEPTH 50 ' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED NA (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 Ordinançs, Jjl and egulations, and all applicable California State Laws. <br />DEPARTMENT USE ONLY <br />Itico6a (t) it-LA ({-0(PT 2_0 _ <br />WORK PLAN DATED: <br />SITE MAP IN UNIT IV FILE, DRESS: <br />,e Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />DEPTH OF GROUT SEAL TO <br />Title/Company Vice President/ Advanced GeoEnvironmental <br />Date 02/08/2007 <br />Signed x <br />Print Name Robert Marty <br />mlan Joaquin County <br />EnvirWmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br /> <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />AN 8:25 <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 />220c- - - , Assessors . A • <br />WELL Location-224-9 Waterloo Road Cross Street Cherokee LaneCity Sete,c4cton' .Lip3 1 Parcel# 11911017 <br />PROPERTY <br />Owner Spencer Reynolds Address 3429 Oak Shores Drive City Stockton Zip 95209 Phone# <br />C-57 Contractor Advanced GeoEnvironmentalAddress 837 Shaw Road City Stockton Zip 95215 Lic# 672617 Phone# 209-467-1006 <br /> <br />t3 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAlagaR 1 0 <br />Consultant / Sub Cntr Advanced GerEnvi ronment al Address 837 Shaw Road City Stockton Lk:It 672617 Phone# 209-467-1006 <br /> <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />KNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />"(SOIL BORING # 51, B2 <br />WELL # <br />fl *Other <br />0 DESTRUCTION (choose type below) <br />O OVER-BORE. DIAMETER <br />O PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />ACCOUNTING ONLY: <br />_ . <br />AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />s R# <br />ODqr) 6 -)) <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />EHD 29-02-001 <br />6/22/04