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�6 � San Joaquin County <br /> Pill ' <br /> �-max �\ <br /> > x1 Environmental Health Department SITE <br /> 600 E. Main Street, Stockton, CA 95202-3029 U <br /> L� � F,` t (;NZATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web : www.sjgov.org/ehd C` }r IV <br /> `/ Well Permit Application FEB 2 <br /> 008 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDFNVIROA !! <br /> Application is hereby made to San Joaquin County for a Permit to construct and/or install the work described. Tf}t9( plj � � ^� 'mtpliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental He'e1tNl e�r��,t"(CEce <br /> ; o� EAST FREMONT ST WATTS ST STOCKTON 95205 Asse$sor5153 -130 - 0 : � <br /> WELL Location Cross Street City Zip Parcel# <br /> PROPERTY FREMONT PLAZA <br /> Owner INVESTMENTS LP Address 2050 EAST FREMONT ST City STOCKTON Zip 95205 Phone# ( 209 ) 931 - 7070. <br /> E <br /> TEST AMERICARANCHO 95742 819548 <br /> C-57 Contractor Address 3195 LNYUNG DRIVE City Zip Llc# Phone# ( 916 ) 638 - 5564 <br /> CORD <br /> ppVA <br /> Consultant / Sub Cntr�VANCED GEOENVIRONMFs837 SHAW ROAD City STOCKTON Lic# 680227 Phone# ( 209 ) 467 - 1006 <br /> GIS Coordinates: X Y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> 4FNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING # DOVER-BORE. DIAMETER <br /> 'WELL # M LJ — l j 0 PRESSURE GROUT <br /> 0 *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA. OF BOREHOLE B ° 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2 " <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS SCH 40 TYPE OF CASING: OSTEEL )PVC p OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL 36 ' TREMIE TYPE TO BE USED: DAUGERS 0 HOSE <br /> 0 AIR SPARGE/ OZONE p PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yes ft90 (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> O SOIL BORING aHAND AUGER GROUT SPECIFICATIONS TYPE II NEAT CEMENT ( PORTLAND) <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH 55 ' )fBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> Mr_ 19 CONDUCTOR CASING PROPOSED NO (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 p epared this application and that the work will be done in accordance with San Joaquin <br /> County Or c RUIe nd Regulations, and all applicable California State Laws . <br /> Signed x Title/Company ADVANCED GEOENVIRONMENTAL , INC <br /> Print Name ARTHUR DEICKE Date 05 NOVEMBER 2007 ^� <br /> DEPARTMENT USE ONLY �® <br /> SITE MAP IN UNIT IV FILE, ADDRESS : ,� n S o �p MnC <br /> WORK PLAN DATED : tl ( INLoH <br /> Application Accepted By Date Issued 3 IqV Area <br /> Grout Inspection By �.�r1M^L' t.. Date t Final Inspection By f Dale <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 3 So 1 84 0' <br /> 353 .$tzgy-oo35s3. o� 2 �- 1 *( 1 �' 3 H �oSs SR# �j � ✓� 2/ ) <br /> C-57 WC -WAIVER. C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> ERD 29-02-001 web <br /> 6/22/04 <br />