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o U .San Joaquin County <br /> r Environmental Health Department EC�F___ <br /> / TE <br /> 600 East Main Street, Stockton, CA 95202-3029 ITION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd SEP 0 4 2009 UNIT IV <br /> ` F R Well Permit Application ENVIRO <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pERMNITcNTN -TH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is Y(i2Flt-id compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location 1943 Fremont Street Cross Street Wizard Ave City Stockton Zip 9520T Parcel# 141-090-39 <br /> PROPERTY Community Bank of <br /> Owner San Joaquin Address 22 West Yokuts Ave CityStockton Zip 95207 Phone# (209)956-7000 <br /> Advanced <br /> C-57 Contractor GeoEnvironmental. Inc, ddress 837 Shaw Road CityStockton Zip952 ,IrLic#680227 Phone# (209)467-1006 <br /> Advanced <br /> Consultant/Sub Cntr GeoEnvironmental, Inc. Address 837 Shaw Road CityStockton Lic# 680227 Phone# (209)467-1006 <br /> GIS Coordinates:X 'y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> g NEW WELL/BORING (CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> g SOIL BORING# B-1 &: B-7 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: Reference AGE-prepared Limited Subsurface Site Assessment Work Plan, dated 01 September 2009 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> B MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 1_25"0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: N/A <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: p STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 25' or 40' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE R PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> R SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Tvpe T/11 neat cement <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 25' or 40' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (if YES,list specifications in comment section) <br /> COMMENTS:Reference AGE-prepared Limited Subsurface Site Assessment Work Plan, dated 01 September 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 /> Signed x Title/Company vice President/Advanced GeoEnvironmental. Inc. <br /> Print Name Robert E. M : v Date 01 September 2009 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: I cl L( 3 e v�.A �S V <br /> WORK PLAN DATED: <br /> Application Accepted By Lth CG L. Date Issued Area ��,, <br /> Grout Inspection By I,f„A,._LGrn Date Final Inspection By Date q I L I/o'I <br /> Destruction Inspection By Date �� <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 /> 7cto`� 9q,00 300e3 (tG 4 eVe7 SR# 5S2-u3 <br /> C-57,/ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD29-02-001 WEB <br /> 9/11/2007 <br />