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i <br /> San Joaquin County <br /> Environmental Health Department Uhl <br /> 600 E. Main Street, Stockton, CA 95202-3029 MITIGATION <br /> • (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd FEB 8 2A IT IV <br /> Lj n Well Permit Application E^>!V!f OJI],r,_', <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED p "U?lT/Ct Oy/Ir�r.0 <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 153-130-03 <br /> WELL Location Cross Street City Zip Parcel# <br /> PROPERTY FREMONT PLAZA <br /> Owner INVESTMENTS LP Address 2050 EAST FREMONT ST CitySTOCKTON Zip 95205 Phone# (209) 931-7070 <br /> C-57 Contractor <br /> TEST AMERICA Address 3195 LUYUNG DRIVE City RANCHO Zip 95742 Lic#819548 Phone#(916)638-5564 <br /> pp Lic# Phone# <br /> ADVANCED GEOENVIRONM 837 SHAW ROAD C <br /> Consultant/Sub Cntr ��t�s City tyS OORDCKTON 680227 (209) 467-1006 <br /> GIS Coordinates:X Y Township Range Section <br /> I <br /> WORK TO BE PERFORMED: <br /> UNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> jrWELL# MO-70 fi [cl- 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> YffMONITORING YffHOLLOW STEM DIA.OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_2"__ <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCH 40 TYPE OF CASING: 0 STEEL WVC 0 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 ITY4o (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' gBOLTED 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 Or In ces,�f2ules and Regulations, and all applicable California State Laws. <br /> Signed x 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: 7 o s C u w o, ✓f- 5-Ec�c �t EvL <br /> WORK PLAN DATED: t t f4(o- - <br /> Application Accepted By A�-s -�c� Date Issued �Y�05� Area <br /> Grout Inspection By Date o Final Inspection By (j�,�,_Date 2$" d <br /> Destruction Inspection By Date <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 /> 35o I 41 Scl•pO <br /> S03z `t.oc ( 33.0o Z� tKI ( 3'y p� SR# S 3sL_aZZ <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 web <br /> 6/22/04 n 6 74= <br />