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San Joaquin County <br />Environmental Health Department <br />600 E. Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />SITE <br />MITIGATION <br />UNIT IV <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 />FremontAssessors <br />WELL Location 1011 North Broadway Cross Street City Stockton Zip 95205 Parcel# <br />PROPERTY <br />Owner Frank Spingolo Address 1011 N. Broadway City Stockton Zip 95205 phone# 465-5675 <br />C-57 Contractor Advanced GeoEnvironmentaAddress 837 Shaw Road City StocktonZip 95215Lic#680227 Phone# 467-1006 <br />Consultant/ Sub Cntr Advanced GecEnvironental Address 837 Shaw Road City Stockton LiC# 680227 Phone# 467-1006 <br />GIS Coordinates: X 'Y Township Range Section <br />WORK TO BE PERFORMED:) <br />[ cNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />UZOIL BORING # 2 soil borings 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS Z <br />COMMENTS: work plan dated 25 May 2007; approved by letter dated 05 June 2007 <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />0 MONITORING <br />0 HOLLOW STEM <br />DIA. OF BOREHOLE 2" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL 20; 65 TREMIE TYPE TO BE USED: GtAUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE <br />D;PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes EKNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />[YSOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS Portland cement <br />0 OTHER:_9 <br />OTHER <br />APPROX. BORING DEPTH 20; 65 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 Or ' nces d Regulat' ns, and all applicable California State Laws. <br />Signed X / � ' Title/Company Vice President/Advanced GeoEnviro'�Rental, Inc. <br />Print <br />SITE MAP IN UNIT IV FILE /�D <br />WORK PLAN DATED:l SSI C <br />Application Accepted E <br />Grout Inspection ByA <br />Destruction Inspection <br />COMMENTS / CONDITIO <br />ACCOUNTING ONLY: I AID# <br />DEPARTMENT USE ONLY <br />RESS: A -bay-C I fife f/t�„ <br />—Date Issued Ar✓�t�► JUN � 1 2007 <br />(,l/ P2PEFMITISE�vi�r A <br />ea <br />al Inspection By Date <br />PE CODES FEE INFO I AMOUNT REMITTED CHECK # REC'D BY I DATE PERMIT / SERVICE REQUEST # INVOICE <br />b <br />C-57_ WC _ -WAIVER C-57 Letter of Authorization to sign permit En <br />EHD 29-02-001 web <br />6/22/04 3s'.0-7 <br />