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San Joaquin County <br />Environmental Health Department <br />600 E. Main Street, Stockton, CA 95202-3029 <br />j 09) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />C� Well Permit Application <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />,,"t% 2 2 2007 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is here y g , oaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />Joa {T�b�lathapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />PFWA',T/9ER\4C0 Miner Ave American Stockton 95202 Assessors <br />WELL Location Cross Street City Zip Parcel# 139-240-12 <br />PROPERTY <br />Ownerpon McPhillips Address 545 East Miner Ave City Stockton Zip 95202 Phone# <br />Advanced Geo Enviro 837 Shaw Road Stockton 95215 680227 209 467 1006 <br />C-57 Contractor Address City Zip Lic# Phone# <br />Consultant/ Sub Cntr AAGE/- Address 837 Shaw Road City StocktonLi,# 680227 Phone# 209 467 1006 <br />GIS Coordinates: X l�Y� Y (ZI . Township Range Section <br />WORK TO BE PERFORMED: <br />VNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) p DESTRUCTION (choose type below) <br />[SOIL BORING # OVER -BORE. DIAMETER <br />a <br />� WELL # Q PRESSURE GROUT .S <br />p *Other GROUT SPECIFICATIONS \ n <br />COMMENTS: V1 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />a MONITORING a HOLLOW STEM DIA. OF BOREHOLE Two a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: NA <br />a EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: a STEEL a PVC 0 OTHER: <br />0 VAPOR UD ROTARY DEPTH OF GROUT SEAL 5 feet TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br />a AIR SPARGE/ OZONE PUSH POIN (GP r CPT)GROUT SEAL PUMPED: a Yes 6 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />I0SOIL BORING AND AUG GROUT SPECIFICATIONS <br />Portland <br />OTHER: I] OTHER APPROX. BORING DEPTH 5 feet a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: Soil vapor samples - <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 OrdinaMes, R es an ulations, and all applicable California State Laws. <br />Signed x4fl" Title/Company Vice President/AGE <br />Print Name RoberttE. Marty Date 20 August 2007 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 545 East Miner Ave <br />WORK PLAN DATED: 07 December 6 / <br />Application Accepted BUate issuesa11 <br />• Area v., <br />Grout Inspection By Date Final Inspection BDate � <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE MIT / SER # <br />INVOICE <br />�0 3 <br />3g3;,74 <br />02, <br />vZ s # ®�! -;I-/ S <br />C -57V WCNel"- WAIVER_ C-57 Letter of Authorization to sign permit oc1b, <br />EH 29-02-001 web <br />6/22/04 <br />