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San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <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 />Assessors WELL Location 602 North California St. Cross Street Oak City Stockton Zip CA Parcel# 139 -165- 09 <br />PROPERTY <br />Owner Gary Stallworth Address 602 North California St .City Stockton Zip 95202 Phone# 209-464-1282 <br />C-57 Contractor Mitchell Drilling Address 7900 Myrtle Ave City Eureka Zip955 03 Lis# 672617 Phone# 707 -444 -9040 <br />Consultant/Sub Cntr Advanced GeoEnvironmental Address 837 Shaw Rd. Citystockton Lic# 680227 Phone# 209-467-1006 <br />Township Range Section <br />WORK TO BE PERFORMED: <br />a NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) ['SOIL BORING # a OVER-BORE. DIAMETER A WELL # VW1 , 2 , VW3 ,VW4 , MW7, MW8 a PRESSURE GROUT a *Other 69 ' 701 GROUT SPECIFICATIONS <br />COMMENTS. 50 I "I' Zo 'TT) T1> Ti) <br />SITE <br />MITIGATION <br />UNIT IV <br />GIS Coordinates: X <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />II MONITORING a HOLLOW STEM DIA. OF BOREHOLE10" /8 l'a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:4 <br />I] EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS SC ti Li() TYPE OF CASING: a STEEL la PVC a OTHER: <br />a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 8 ' -56 ' TREMIE TYPE TO BE USED: Ef AUGERS D HOSE <br />U AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes D No (NOTE: MAXIMUM FREE-FA/ / DEPTH IS 30') <br />U SOIL BORING 1:1 HAND AUGER GROUT SPECIFICATIONS Portland Type II <br />O OTHER: a OTHER APPROX. BORING DEPTH 20 ' -70 ' acBOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED NA (if YES, list specifications in comment section) <br />Two monitoring wells (2" diameter)and four soil vapor extraction wells (4" diameter), see work plan. <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />4U 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 Ordinances Rule and eg ationsI and all applicable California State Laws. <br />Signed x Title/Company Staff Scientist/Advanced GeoEnvironmental <br />Print Name Alison Colavita Date n4/n5/n7 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: ‘0 2- CckAA-6-cs-Nim"-Sft-e-c---4 <br />WORK PLAN DATED: 241 Jo <br /> <br />Application Accepted By 1/6-4.1.NA.ral,^s. <br /> <br />Date Issued 4110/0 ?- <br />Date 4-1 I I IS 1.0-+ Final Inspection By t/NIAI&CrAle. ate '-1 <br />Date <br /> <br />2,0107- Grout Inspection By CA->rtinnect <br />Destruction Inspection By <br /> <br />COMMENTS: <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # 5 EC'D BY DATE PERMIT/ UEST # INVOICE <br />4 co 1 <br />350- <br />Vet . c, a Z_S-CO Z -- <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign per c <br /> <br />EHD 29-02-001 <br />6/22/04