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'oPq�[N o San Joaquin County 40 <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> '9L1F0'Rt� 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.Assessors <br /> WELL Location 602 North California St. Cross Street Oak City Stockton Zip CA Parcel# 139-165-09 <br /> PROPERTY 209-464-1282 <br /> Owner Gary Stallwcrth Address 602 North California st.City Stockton Zip 95202 Phone# <br /> C-57 Contractor Mitchell Drilling Address 7900 Myrtle Ave City Eureka Zip95503 Lic#672617 Phone# 707-444-9040 <br /> Consultant/Sub Cntr Advanced GeoEnvironmentai Address 837 Shaw Rd. Citystockton LIC# 680227 Phone# 209-467-1006 <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER") 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# VWl V 2 VW3 VW4 MW7 MW8 0 PRESSURE GROUT <br /> 0'Othercn -' GROUT SPECIFICATIONS <br /> _ <br /> COMMENTS: SO`m ?""TT-.) Tb T1� -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> l]MONITORING HOLLOW STEM DIA.OF BOREHOLE1011 8 [MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:4"/2" <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS S 14 LN TYPE OF CASING: 0 STEEL 8 PVC 0 OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 8'-56' TREMIE TYPE TO BE USED: IJAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes [ No (NOTE: MAXIMUM FREE-FA/ / DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland TVpe II <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 20'-70' [{BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NA (if YES,list specifications in comment section) <br /> COMMENTS: 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 Regulations, and all applicable California State Laws. <br /> Ill <br /> Signed x �' Title/Company Staff Scientist/Advanced GeoEnvironmental <br /> Print Name Alison Colavita Date n4/os/o7 <br /> DEPARTMENT USE ONLY \ �` <br /> SITE MAP IN UNIT IV FILE, ADDRESS: AO z <br /> WORK PLAN DATED:_ <br /> Application Accepted By cv11�1 Date Issued `l 1 l of D 7-- �a <br /> Grout Inspection By y\--k AAe-CA . Date D Final Inspection By fiW M,Fig ` - Date Zc D <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: - <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK it urC'D B, PERMIT/SERVICE REQUEST# INVOICE <br /> � S R# <br /> C-57,__ WC_: /AIVER C-57 Letter :)t Authorizot,,,n to sign permitX Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />