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GEOLOGICAL TECHNICS <br /> 11/29/2007 10:39 209522492 Qooa <br /> V <br /> DECLi t> 1 <br /> 4Z41_6 <br /> 2007 San Joaquiin CountySITE <br /> �I � ental Health. Department <br /> { ENVIRG(1 VOW Avenue,3rd Floor, Stockton_ CA 95202 IVIiTIGATICIN <br /> P hi -3449)=ax: (ZO9}468-1433 Vvebi urx"�'.sjgov,org/eizd 11ldlT IV <br /> Well Permit Appiicaltlon <br /> NON-REFUNDABI-E PERMIT EXPIRES 1 YEAR FROM GATE ISSUED i <br /> 9-1115.3 in compliance�r+rSan <br /> tile work <br /> ryRhImade <br /> Application is hereboae0Sanoagmrh' contr <br /> Joaquir County 0a pmChapter and tS`aof San Joaquijjor n County Environmental Health Department <br /> Assessors 167-181-01 <br /> 9520' <br /> 814 E.Charter Way Cross Street Grant Street_Cm Stockton Zip_.��_Parcel# <br /> WELL Location — 9520 L9 <br /> RAS)AA-0 HvsSAIAt 352,6' C+A�Y,011,*410 R0 (209)478-7546 <br /> PROPERTY Frank Morita Address 6622 Belmont Place City Stockton Zlp 95207 phone# <br /> Owner Rancho Cordova (916)653-8010 <br /> TEG 11350 Monier Park Place Clty Zip 95742Lic#706568 Phone# <br /> C•s7 Contractor TEG (209)522-4119 <br /> Consultant!Sub Cntr <br /> Geological Technics Inc Address 1101 7th Street City Niodest0 Lic# n/a Phone# <br /> GIS Coordinates:X ,Y ,Township Range _Section- <br /> WORK TO eE PERFORMED: <br /> p NEW WELL I BORING (CPT,OEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> n SOIL BORING# a OVER-BORE, DIAMETER <br /> — <br /> a WELL p PRESSURE GROUT <br /> a*Other GP-1 GROUT SPECIFICATIONS <br /> COMMENTS: See Work Plan dated 11/30/2006 and Work Plan Addendum dated 8/13/07 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE, Q MULTIPLE CASINGS Q MULTI-LEVI=L WELL CASING DIA: <br /> Il EXTRACTION Q AIR HAtAkIERIORIVEN CASING THICKNESS TYPE OF CASING; D RTE!_L U PVr„ I1 OTHER: _____-_ <br /> [)VAPOR a MUD ROTARY DEFTH OF GROUT SEAL TREMk TYPE TO BE USED: []AUGERS a HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)CROUT SEAL PUMPED, Q Yes a No (MOTE.: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING a HAND AUGER GROUT SPECIFICATIONS_ - <br /> 0 OTHER: tt OTHEr? APPROX,BORING DEPTH. 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,liet specifications in comment section) <br /> COMMENTS: See Work Plan dated 11/30/2006 and Work Plan Addendum dated 8/13/07 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS, <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 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 /> S!gnsd^ t_1 _ ���p} `,�11 i �TitleJCompany Stc'- oc"'t <br /> Print Name. Ev�r�n 'J• W 4 tIt w50v Date <br /> k DEPARTMENT USE ONLY <br /> SITE MAP 1N UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Acceptt,d By / 6'/, _ Date <br /> Issu®d_ / 28 U _ 1'41:5 <br /> Area <br /> Grout Inspection By '� Data,_- 31 _Final Inspection By,.»_ „A-_ j_jL ---Date—G 12-- <br /> Dartnrction inspection By Date <br /> COMMENT 8/CONDITIONS: <br /> FACC'DUN'TING,ONLY: AID# FP.t,# <br /> f PE CODES PEE INFO AMOUNT REMITTED CHECK# I Rte• EC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> CA C�`-K �7 - <br /> s5vi of L'0�32 <br /> 1-3503 �383• eO ZD i O � SRS# L•f <br /> C-57-- WC -WAIVER____ C-57 Letter of Authol'i=ation to sign permit Encroachment doc <br /> EHD 29--02-001 <br /> 6/22/04 <br />