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Po.'.!ry San Joaquin County <br />z� Environmental Health Department <br />jai :1304 East Weber Avenue, 3rd Floor, Stockton, CA 95202;;, ^„ <br />^ <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.orgYc�I ( <br />� <br />_, <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <br />0 2007 <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 />Assessors <br />WELL Location 2850 Loomis Rd. Cross Street Mariposa Rd. City Stockton Zip 95205 Parcel# 179-100-03 <br />PROPERTY -f:bWi_Ot IGli�"P1�Svl, �%✓tyl�� Cfor1fCL2 "! 9!SG2727 <br />"-,/'0 <br />Owner—Vineland aeE ar�E.-. Address 71 Wes Park Ave City Vineland, NJ Zip 08360 Phone#� YJ �p �/'�h�jY <br />C-57 Contractor cascade Drilling, Inc. Address 3652 Omac Circle CityRar.cho cordovaZip Lic# r1/7 5/ Phone# (-//(, ry�� �IG <br />Consultant/ Sub Cntr Advanced Geo Environmental Address 837 Shaw Rd City Stockton Lic# c� (-'7 C %'hone# -;,20 <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />$SOIL BORING # B-2 0 OVER -BORE. DIAMETER <br />E WELL # MW -6 0 PRESSURE GROUT <br />0 'Other GROUT SPECIFICATIONS <br />COMMENTS: Z) <br />ACCOUNTING ONLY: AID# FAC# <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />FEE INFO <br />R MONITORING H HOLLOW STEM DIA. OF BOREHOLE8 . 25" MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: -2. 0" <br />CHECK # <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC BOTHER: Blank <br />_ <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 120' /150' TREMIE TYPE TO BE USED: 0 AUGERS E HOSE <br />�. <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 />B SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Type I/I I Portland neat cement <br />25,/4 <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 13 i7 and 150' $ BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />UD5 D <br />SR#If <br />CONDUCTOR CASING PROP 96 S ? (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 Ordinan %ga2fegulations, and all applicable California State Laws. <br />''Y'l h S4 /1'k/ tnrrc l �}Qd r1 U iC amPn�a( Mc <br />''- i C%r1 <br />' vice President/ Advanced GeoEnvironmental, Inc. / <br />T7 <br />Signed x c Title/Company <br />Print Name Robert Marty Date 30 April 2007 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: Z. S 5"0 L o Yq .S 1 o ci ai S+ o, --k -�o n - (17 A <br />WORK PLAN DATED:\ m b er 10 '20 0 <br />/Nl)Ve <br />Application Accepted By V I c Y- l.1r f Date Issued M',I 2100 17 Area `T <br />Grout Inspection By N;/. c -to y 1 4 mC& r1 -n"-; Date 511,q416(101 Final Inspection By ��`�Al�. i �` L'GyfYIE�Date -7 <br />Destruction Inspection By Date <br />COMMENTS/CONDITIONS: ( 11"rvPf "ani <br />APtri/7h <br />L L)0r�o1eQ-7 r)rr11 "--0 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P ST # <br />INVOICE <br />25,/4 <br />UD5 D <br />SR#If <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment oc_ <br />EHD 29-02-001 <br />6/22/04 <br />