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UIN �o *San Joaquin County • <br /> Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 �� ((�I��i11Glulv�lllON <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.sigov.org/eh Vv f ��''JJ�• ITI <br /> ` FOR P Well Permit Application SEP 0 4 2009— <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This��My�E�N@TdHEALTpliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental He Alth'DL�i'dHrtldnt! V BCJJ <br /> WELL Location 1943 Fremont Street Cross Street Wizard Ave City Stockton Zip 9520r Assessors <br /> a parcel# 141-090-37 <br /> PROPERTY Community Bank of <br /> Owner_ San Joaquin Address 22 West Yokuts Ave pity Stockton Zip 95207 phone# (209)956-7000 <br /> Advanced <br /> C-57Contractor GeoBnvironmen al Inc Address 837 Shaw Road CityStockton Zip 952tjrUc#680227 phone# (209)467-1006 <br /> Advanced <br /> Consultant/Sub Cntr GeoEnvironmental, Inc. Address 837 Shaw Road City Stockton Lie# 680227 Phone# (209)467-1006 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> S NEW WELL/BORING (CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') D DESTRUCTION (choose type below) <br /> HSOILBORING# B-6 & B-8 DOVER-BORE. DIAMETER <br /> D WELL# <br /> a*Other D PRESSURE GROUT <br /> 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 /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE 1_25 ,a MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: nt/n <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER: <br /> D VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 25' or 40' TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE/OZONE 8 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> R SOIL BORING D HAND AUGER GROUT SPECIFICATIONS Tvne T/II neat cement <br /> D OTHER: N OTHER APPROX.BORING DEPTH 25' or 40' D BOLTED TRAFFIC BOX or D 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_A( <br /> Title/Company Vice President/Advanced GeoEn ironmental Inc. <br /> Print Name Robert E. h.rrt_v Date 01 September 2009 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, DD ESS: I I Y-22 f <br /> WORK PLAN DATED: qp� <br /> Application Accepted By Date Issued ev!'201 Area <br /> Grout Inspection By IINAA+ACo�Date Final Inspection ByDate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2goS � ,o0 3c � C( je7 SR# S K Z`6S <br /> C-57_1Z WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD29-02-001 WEB <br /> 9/11/2007 <br />