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San Joaquin County <br />Environmental Health Department �',` SITE <br />600 E. Main Street, Stockton, CA 95202-3029 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd FEB U 8 !SNIT IV <br />Well Permit Application ENVIRON `! 1-- , <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 />2050 EAST FREMONT ST WATTS ST STOCKTON 95205 Assessors 15 3 - 13 0 - 03 <br />WELL Location Cross Street City Zip Parcel# <br />PROPERTY FREMONT PLAZA <br />Owner INVESTMENTS LP Address 2050 EAST FREMONT ST <br />C-57 Contractor <br />TEST AMERICA Address 3195 LUYUNG DRIVE <br />Consultant / Sub CntrADVANCED GEOENVIRONMIX' ,837 SHAW ROAD <br />GIS Coordinates: <br />, Township <br />CitySTOCKTON Zip 95205 Phone# (209) 931-7070 <br />City <br />RANCHO Zip 95742 Lic# 819548 Phone# (916)638-5564 <br />_ <br />CORD <br />Q <br />City 1 C OAKTON Lic# 680227 Phone# (209) 467-1006 <br />Range <br />Secti <br />WORK TO BE PERFORMED: <br />>TNEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />JrWELL # ltit 0- Z D 0 PRESSURE GROUT <br />0 *Other rGROUT SPECIFICATIONS <br />COMMENTS: — <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />Yff MONITORING HOLLOW STEM DIA. OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCH 40 TYPE OF CASING: STEEL PVC OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 107' TREMIE TYPE TO BE USED: ffAUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes tfrlo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS TYPE II NEAT CEMENT (PORTLAND) <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 122' [;BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED NO (if YES, list specifications in comment section) <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 />CountyRegulations, and all applicable California State Laws. <br />Signed xOr in ces, ules and Title/Company ADVANCED GEOENVIRONMENTAL, INC <br />Print Name ARTHUR DEICKE Date 05 NOVEMBER 2007 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 7q -;- <br />WORK <br />o - <br />WORK PLAN DATED: y -- <br />Application Accepted By Date Issued —Area <br />Grout Inspection By Date o Final Inspection By�-�n,v.� <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />350 ( <br />t 19cl•pOSR# <br />00 <br />��t�rl <br />( <br />�J� o� <br />s <br />so3 <br />#214-o� <br />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br />EH 29-02-001 web <br />6/22/04 <br />