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�"oPqU1. coo San Joaquin County I�E Wv/+E L) <br /> z� Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MAR 2 v 200KAITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> ENV1R0N%1ENT HEA?TWNIT IV <br /> q�►FpRN Well Permit Application PERMIT/SERVIGEG <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> CITY OF STOCKTON ROW <br /> WELL Location 2050 EAST FREMONT ST Cross Street LAUREL ST City STOCKTON Zip 95205 Parcel#Assessors <br /> PROPERTY <br /> Owner City of Stockton Address 22 East Weber Ave City Stockton Zip 95202 Phone# (209) 937-8411 <br /> Advanced GeoEnvironmental <br /> C-57 Contractor Address 837 Shaw Road City Stockton Zip 95215 Li 680227 Phone#209-467-1006 <br /> Advanced GeoEnvironmental <br /> Consultant/SubCntr Address 837 Shaw Road City---------- Lie# 680227 Phone# 209-467-1006 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: 1 v <br /> )aNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) 0 <br /> ,USOIL BORING# B-10 a OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: l✓ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (`t <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE 1.5 Q MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 65 feet TREMIE TYPE TO BE USED: ff:AUGERS o HOSE <br /> a AIR SPARGE/OZONE %€}'fPUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes Zvo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> xg SOIL BORING p HAND AUGER GROUT SPECIFICATIONS TYPE II/PORTLAND CEMENT <br /> a OTHER: a OTHER APPROX.BORING DEPTH 65 FEET 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 Ordinalnces,;'Rute nd Regulations, and all applicable California State Laws. <br /> Signed x�( -14-C Title/Company VP/Advanced GeoEnvironmental, Inc. <br /> Print Name ROBERT E. MARTY ' i Date v <br /> `� DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 'Z c)S o -4-.c P%,-tn� $-- <br /> WORK PLAN DATED: / c� <br /> Application Accepted By Date Issued Y I 1 o Area <br /> Grout Inspection By (� ,�c�.-� Date 1370 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# �26 42 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ,Sot fsq.00 53��� <br /> -0 3 za`(-o o 23303 y life,S- SR# <br /> C-57 ✓ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc✓ <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />