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mml <br />„A, liyuppATIoN <br />ENVIRONME.N Hc-I\LTH <br />PERM1T/SERVICES <br />Sig <br />Print Name Lauren Cardinal- <br />in 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 <br /> Cross Street Cherokee City Stockton Zip CA Parcel# 132-060-08 <br />TeiYm;y10,11 (2.0,094 8307 5721y0 8 PROPERTY Prty <br />Owner Mrs • r'ia Moo Address 3480 -Newton Read City Stockton Zip 9520 1Phone# (209) 466-3201 <br />All Well Abandonment C-57 Contractor Address 3809 Pleasant Valley Road City Placervillezip 95667 Lic# 84 8359 phone# (800)948-1355 <br />Consultant / Sub Cntr Advanced GeoEnvironmental Address 837 Shaw Rd . CityStockton Lico 680227 Phone# 209-467-1006 <br />, Township Range <br />U DESTRUCTION (choose type below) <br />a OVER-BORE. DIAMETER <br />U PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />1W-5 through MW -7 wells are monitoring wells (2.diameter,51.grout,70'total depth). <br />COMMENTS: MW-8 wells are monitoring wells (4ndiameter,56'grout,70'total depth). <br />TYPE OF WELL <br /> INSTALLATION TYPE <br /> CONSTRUCTION SPECIFICATIONS <br />[rMONITORING <br /> <br />E HOLLOW STEM <br /> DIA. OF BOREHOLE8 -10” E MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 2-4 <br />a EXTRACTION <br /> <br />U AIR HAMMER/DRIVEN CASING THICKNESS SCH 40 TYPE OF CASING: a STEEL El PVC a OTHER: <br />a VAPOR <br /> <br />O MUD ROTARY DEPTH OF GROUT SEAL 51 to 56 ' TREMIE TYPE TO BE USED: a AUGERS U HOSE <br />U AIR SPARGE/ OZONE U PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />SOIL BORING <br /> a HAND AUGER GROUT SPECIFICATIONS Portland Type I /II <br />U OTHER: <br /> <br />O OTHER APPROX. BORING DEPTH 70 ' a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED (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 />WELL Location 3400 Newton Road <br />WORK TO BE PERFORMED: <br />[f NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />fl SOIL BORING # <br />ricWELL # MW-5, MW-6, MW-7, MW-8 <br />GIS Coordinates: X , Y <br />a *Other <br />I hereby c that I have pre ared this application and that the work will be done in accordance with San Joaquin <br />Cou nces, Rules egulations, an • all applicable California State Laws. <br /> Title/Company Staff Geoloqist/Advanced GeoEnvironmental , Inc. <br />Date 05/16/08 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 34D 0 New+on <br />WORK PLAN DATED: March ) 2.008 <br />Application Accepted By, V i 'ock L, e <br />Grout Inspection By Y Jr1 0, rnditirhlUi Date (if 14') 0 a <br />Destruction Inspection By Dat <br />Date Issued 513d 1),14 Area <br />Final Inspection By Nir ori4 tetfr1174-7 Date 6 / -0 8 <br /> <br />COMMENTS / CONDITIONS: Y1S1-,e1l )1 4- ; 0+ -yr) ern r Leh'. i/ mi-c 11741-4 174 -7 4,4 -,9 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! - • s # INVOICE <br />3g0/ <br />3..ro 3 <br />4Y 89.o 0 ..2.9Y, o 0 <br />4Y 3 8 , 7 6 5-q Lvo-in c-131,100R# 0005"44 0 & <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit x Encroachment doc <br /> <br />EHD 29-02-001 <br />6/22/04