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mFjEc�G FINAL <br />^.: San Joaquin County <br />Environmental Health Department FEB2, 5 2008 SITE <br />600 E. Main Street, Stockton, CA 95202-3029 MMI�TIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org%.1110IT/SERVICHI <br />IEAT�'UNIT IV <br />g` ....,..., Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED o�• 'Roup <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 />County Ri ht -Of -Way, lmwood Ave. Elmwood/Franklin Stockton 95204 Assessors /} Row <br />WELL Location0 Cross Street City Zip Parcel# w <br />In front of 2128, 2136 & 2142 Elmwood Ave. <br />PROPE <br />Owner San Joaquin County Address1810 E. Hazelton Ave. City Stockton Zip 95201 Phone# 209-468-3000 <br />C-57 Contractor A.G.E. Address 837 Shaw Rd. City Stockton Zip 95215Lic# 680227Phone# 209-467-1006 <br />Consultant/ Sub Cntr A.G.E. Address 837 Shaw Rd. City Stockton Lic# 680227 Phone# 209-467-1006 <br />GIS Coordinates: X 'Y Township Range Section <br />WORK TO BE PERFORMED: <br />xn NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />RGOIL BORING # 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other S GROUT SPECIFICATIONS <br />COMMENTS: See EHD-Approved Work Plan, dated 15 January 2007 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2 11 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL 5' <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE <br />TPUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes <br />4] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />Xf]}SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS TYPE <br />II NEAT CEMENT (PORTLAND) <br />0 OTHER: <br />0 OTHER <br />APPROX. BORING DEPTH 51 <br />0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED NO (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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x Wkn__ Title/Company ADVANCED GEOENVIRONMENTAL, INC <br />Print Name TIMOTHY J. CUELLAR Date 25 FEBRUARY 2008 <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />2-1 -,, 5: r <br />Application Accepted By �L� Date Issues <br />Grout Inspection By Dat Final Inspection <br />Destruction I <br />COMMENTS/ <br />Date <br />IV°'.1 d <br />Low <br />66E_q <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />P UEST # <br />INVOICE <br />S03�� <br />383• <br />Z��{ <br />zL2_ <br />SR#�®�3SP� <br />C-57 `/ WC `/ -WAIVER <br />EHD 29-02-001 web <br />6/22/04 <br />C-57 Letter of Authorization to sign perrrti oc • aj05'p % <br />*,R• y15• °k <br />