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Well Permit Application <br />ENVIRONMENU HEAL TI NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS arM111T/SERVI(NF <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 1130 South Pilgrim Street 51-350 -01 Cross Street Jackson St. City Stockton Zip CA Parcel# <br />PROPERTY Mohammad Saeed <br />Owner Islamic Center of Stockton Address C1130 South Pilgrim Stree6.ty Zip Stockton 95205 Phone# (209) 607 -4956 <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202' <br />Environmental Health Department <br />MITIGATION <br />SITE <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.orgighd <br />6 UNIT IV cii06 <br />- <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />fl HOLLOW STEM DIA. OF BOREHOLE' 1/ 4 II MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br />D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: El STEEL [I PVC [I OTHER: <br />o MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />O PUSH POINT (GP or cP-0GROUT SEAL PUMPED: El Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />El HAND AUGER GROUT SPECIFICATIONS Portland Type I/II <br />or a STOVE PIPE [I OTHER: 11(0THER Geoprobe APPROX. BORING DEPTH 60' 0 BOLTED TRAFFIC BOX <br />/c4 Area q97 <br />San Joaquin County <br />city Stockton zip 95215Lio#680227 phone#209-467-1006 <br /> Address City Lic# <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />Er NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) D DESTRUCTION (choose type below) <br />Ef SOIL BORING # B-1 /3- Z_ DOVER-BORE. DIAMETER <br />D WELL # D PRESSURE GROUT <br />Q *Other GROUT SPECIFICATIONS <br />COMMENTS: 8-4 hj/cd) (5 -1 'to IC' j fit5kretAzt <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 />his application and that the work will be done in accordance with San Joaquin <br />tions, and all Applicable California State Laws. <br />Title pany Staff Geologist/Advanced GeoEnvironmental, Inc. <br />I hereby ce <br />County Or <br />that I have prepa <br />nces, Rules an <br />Signed <br />Print Name Lauren Cardinalli Date 06/06/08 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE,,ADDRESS: o 5. <br />WORK PLAN DATED: -h.& gi a/-0637 Mrt <br />Application Accepted By , <br />Grout Inspection By Date <br />Destruction Inspection By Date <br />toP 5L &1 - / COMMENTS / CONDITIONS: <br />doc nc C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br />09-9V— <br />EHD 29-02-001 <br />6/22/04 , 3 0-5 (3-r <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE CE R T# <br />SI— .A7 '....7i c Al S R#075--45-6 / <br />TYPE OF WELL <br />fl MONITORING <br />El EXTRACTION <br />[I VAPOR <br />D AIR SPARGE/ OZONE <br />rt SOIL BORING <br />same as above Consultant / Sub Cntr Phone# <br />C-57 Contractor Advanced GeoEnvironmentalAddress 837 Shaw Rd. <br />3 <br />c/) <br />Date Issued <br />Final Inspection By Date