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q Oan Joaquin County • FILE COPY <br /> UI <br /> °;oe <br /> Environmental Health Department SITE <br /> �(� 11Q� ATION <br /> m < 600 East Main Street, Stockton, CA 95202-3029 I��llll VV <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.or NIT IV <br /> ° Irab V Well Permit Application JAN 4 2 _ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ``II''QQ ^� T HEALTH C� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describe pig+#g�trjiD compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmentaaft�C 95206 N Assessors Cos R-O-w <br /> 0- -'t " T. _ , Stockton <br /> WELL Location ZT 2rZ1 Jf3�t:5oN Cross Street Center City Zip Parcel# <br /> PROPERTY City of Stockton Address <br /> North El Dorado St City Stockton Zip 95205 Phone# 209-937-8366 (PW) <br /> Owner <br /> Advanced GeoEvironmental 837 Shaw Road Stockton 95215 680227 209-467-1006 <br /> C-57 Contractor Address City Zip Lic# Phone# <br /> A.G.E. Address 837 Shaw Rd. City Stockton Lic# 680227 Phone# 209-467-1006 <br /> Consultant/Sub Cntr 1 <br /> GIS Coordinates:X_ 3 ,Y 'I� Z Township Range Section <br /> WORK TO BE PERFORMED: <br /> d NEW WELL I BORING SPT/ OPROPE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 CTIN se type below) <br /> 1]SOIL BORING# Pi/ V4OVER-BORE. DMETER <br /> ` <br /> a PRESSURE GROUT ^7 <br /> a WELL# GROUT SPECIFICATIONS <br /> - <br /> a"Other �\ <br /> COMMENTS See Soil Vapor Survey Work Plan 19 October 2009 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE?°° 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL G PVC 0 OTHER: <br /> a VAPOR YHANDAUGER <br /> LIGROUT SPECIFICATIONS D ROTARY DEPTH OF GROUT SEAL 5- TREMIE TYPE TO BE USED: 0AUGERS a HOSEIRSPARGE/OZONEUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Portland (Type II) <br /> SOIL BORING <br /> a OTHER:_G OTHER APPROX.BORING DEPTH 5' a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (if YES,list specifications in comment section) \�C <br /> COMMENTS: See EHD-approval letter, dated 09 November 2009 <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 Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Project Manager/A.G.E. <br /> Signed x lam' TitlelCompany <br /> Date 22 December 2009 <br /> Print Name William Little v)l <br /> DEPARTMENT USE ONLY -�' �� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: OC-Y'0 <br /> Date Issued Area <br /> Application Accepted By Date <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Dale <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> .IQ SR# / 6 <br /> C-5 ter— WC WAIVERµ� C-57 Letter of Authorization to sign permit Enc roachment�//doync_//�� ayA! <br /> EHD29-02-001 WEB p / � C ■ <br /> 9/1112007 <br />