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a4uln San Joaquin County <br /> z ,4 Environmental Health Department CC <br /> (w } 600 E. Main Street, Stocicton, CA 95202-3029 MITIGATION <br /> (209) 468-3449 Fax : (209) 468-3433 Web : wwv✓.sjgov.org/ehd FEBa 2ENIT IV <br /> Well Permit Application EN!JlPrON 1J, _ T <br /> f)f7. Dr/! i roll I r ^ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I ° I J <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 /> 2050 EAST FREMONT ST WATTS ST STOCKTON 95205 AssessOrS153 - 130 - 03 <br /> WELL Location Cross Street City Zip Parcel# <br /> PROPERTY FREMONT PLAZA <br /> Owner INVESTMENTS LP Address 2050 EAST FREMONT ST City_ TOCKTON Zip 95205 Phone# ( 209 ) 931 - 7070 <br /> C-57 Contractor <br /> TEST AMERICA Address 3195 LUYUNG DRIVE City RANCHO 95742 LidF 819548 Phone# ( 916 ) 638 - 5564 <br /> Zip <br /> CORDOVA <br /> Consultant / Sub CntrADVANCED GEOENVIRONMFA' &&S837 SHAW ROAD City STOCKTON Lic# 680227 Phone# ( 209 ) 467- 1006 <br /> GIS Coordinates: X , Y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> VIEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) D DESTRUCTION (choose type below) <br /> 0 SOIL BORING # 0 OVER-BORE. DIAMETER <br /> IPWELL # )MW- Z0 -r g /,iJ - aPRESSURE GROUT <br /> 0 *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING #HOLLOW STEM DIA. OF BOREHOLE 8 " 0 MULTIPLE CASINGS ]] MULTI-LEVEL WELL CASING DIA: 2 <br /> EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS SON 40 TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 107 ' TREMIE TYPE TO BE USED: 03'AUGERS 0 HOSE <br /> 0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yes ITNo (NOTE : MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS TYPE II NEAT CEMENT ( PORTLAND) <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH 122' D: BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 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 prepared this application and that the work will be done in accordance with San Joaquil6. <br /> County Or n c s, ules nd Regulations, and all applicable California State Laws. r� <br /> Signed x 5 �`' 'v '� Title/Company ADVANCED GEOENVIRONMENTAL , INC <br /> Print Name ARTHUR DEICKE Date 05 NOVEMBER 2007 <br /> DEPARTMENT USE ONLY C= <br /> SITE MAP IN UNIT IV FILE, ADDRESS : 7 os O r w� / 5 Ivc li Fv < <br /> WORK PLAN DATED :.-( L f ) <br /> Application Accepted By ` Imo-- r ri Date Issued c/ LO 5: Area <br /> Grout Inspection By tADate o Final Inspection By Date 2$ b <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTEHECK # REC'D BY DATE PERM <br /> REMITTEDCHECK IT I SERVICE REQUEST # INVOICE <br /> iso r ev 1`1�0 SR# <br /> r5-03 {.t2 .°e as3. 00 z �- t �fl 3 � K 5 3 S ZZ, <br /> C-57_ WC.-WAIVER. C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> END 29-02-001web <br /> 6/22/04 <br />