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AEC ERIED NOV 1 3 2GC7 <br /> San Joaquin County <br /> DEC 14 2007 <br /> z � Environmental Health Department SITE <br /> to ,, rt, :-;. IRONMEI14Wb NTeber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> c "' P <br /> ERN 449 Fax: (209)468-3433 Web: wwwsjgov.org/ehd UNIT IV <br /> 4�;FoN` <br /> 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. <br /> 814 E.Charter Way Grant Street Stockton 95207 Assessors 167-181-01 <br /> WELL Location Cross Street City Zip Parcel# <br /> R4514A0 HJ55f1%N 352-5 (APYOVIANp 1ZoA9 9S269 <br /> PROPERTY Frank Morita 6622 Belmont Place Stockton 95207 (209)478-7546 <br /> Owner Address City Zip Phone# <br /> C-57 Contractor Precision Sampling Address 1081 Essex Avenue City Richmond Zip 94801 Lic#636387 Phone4(916)853-8010 <br /> Consultant/Sub Cntr Address City <br /> Geological Technics Inc 1101 7th Street MoLic# Phone# <br /> desto n/a (209)522-4119 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) Q DESTRUCTION (choose type below) <br /> Q SOIL BORING# SB-2 Q OVER-BORE. DIAMETER <br /> Q WELL# Q PRESSURE GROUT <br /> Q*Other 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 /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: flAUGERS Q HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER: Q OTHER APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list 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 /> 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 /> Signed x Title/Company �S/�"� 4y G <br /> Print Name r I N Date "9,—y( d <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued r Area <br /> Grout Inspection By_��L Date 27 Z*�Final Inspection By /Lz'` Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> FLACCOUNTING ONLY: AID# FAC# <br /> FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> &3 19935 CAMIk iz �y �9 sR# by 15 235 <br /> C-57_ WC--WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />