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G. <br />Aan Joaquin County <br />t3' <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />D (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />Well Permit Application <br />FF %% 77 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />App( &ion Ph re6y00ade to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />�1o�gy�j {� �Y v�Jpppp Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />t��UltiL'�I��CN� �t� Assessors <br />€Q at Blvd Cross Street Cowell AveCity Manteca Zip 95337 Parcel# 22/ /S'00.15' JJ <br />PROPERaymond Investment 817 South Center St Stockton 95202 466-8604 �'�� <br />OwnerR Address City Zip Phone# <br />Cascade Drilling INC. 3632 Omec Circle Sacramento 95742 717510 916-638-1169 <br />C-57 Contractor Address City Zip Lic# Phone# <br />Consultant / Sub Cntr Advanced GeoEnvironmentai ddress g' 7 .4h,aw Rrl City Stockton Llc# 680227 Phone# (209)467-1006 <br />GIS Coordinates: X , Y <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING <br />0 SOIL BORING # _ <br />0 WELL # <br />O'Other <br />COMMENTS: <br />Township Range, <br />(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER') <br />Section <br />ff DESTRUCTION (choose type below) <br />[kOVER-BORE. DIAMETER eight and twelve <br />0 PRESSURE GROUT inch drill outs <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[;MONITORING it HOLLOW STEM DIA. OF BOREHOLE 8 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2 inch <br />0 EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS na TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 30 feet TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland <br />0 OTHER: p OTHER APPROX. BORING DEPTH 30 feet BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: destruction of monitoring wells <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 Rul ations, and all applicable California State Laws. <br />Signed Title/Company Geologist / AGE <br />Print Name <br />William Little Date 31 August 2007 <br />DEPARTMENT USEONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 99-3 l� D -t- �r41- e 1 �/i1( <br />WORK PLAN DATED: ,� A t1 3 0 Z © <br />/ <br />Application Accepted By Y ,' Gtbb r is L M e- �?�fi2� Date Issued c7— / ! -0 '7 Area <br />Grout Inspection By I � ,�f Ott', r, L. Y12 er r ��_Date � J � t `7 Final Inspection By ✓ i' bjbY" 10 Vc'& - ZZDate <br />Destruction Inspection By qj jj)' ,La Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT # INVOICE <br />p 2 <br />'� 29 4 3 5'4' . O © <br />a � / /0 402t. <br />i o'? # QoQJ94,S <br />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ ncroachment doc <br />EHD 29-02-001 <br />6/22/04 <br />D <br />f� <br />V , <br />