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T <br /> or 5 <br /> a San Joaquin County f L <br /> q Q a ` Environmental Health Department <br /> L9 600 u u �� � S <br /> f ''7 600 East Main Street, Stockton, CA 95202-3029 A p d 2py� prI ITE <br /> / (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br /> . `'rrFATION <br /> aR"� ENVIRUNIVILNT HE�.�MT IV <br /> Well Permit Application PERMIT/SE <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 /> WELL Location 517 West Fremont Street Cross Street N Lincoln St Ci Stockton Assessors <br /> ty Zip 95203 parcel# 137 - 214 - 10 <br /> PROPERTY <br /> Owner Dave & Pat Guardino Address 517 W Fremont St City Stockton Zip 95203 phone# ( 209 ) -466 - 9678 <br /> Uuaratn0 Corctv�ne On C_'.o*r\P'x1lvr <br /> C-57 Contractor RSI Drilling Address 220 N East St City Woodland Zip 95776L1c#802334 phone# ( 530 ) 668 - 2424 <br /> Advanced <br /> Consultant / Sub Cntr GeoRavironmental Inc Address 837 Shaw Road city Stockton Lic# 680227 Phone# ( 209 ) 467 - 1006 <br /> GIS Coordinates: X., Y., Township Range Section <br /> WORK TO BE PERFORMED: <br /> ` NEW WELL / BORING (CPT GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER`) 0 DESTRUCTION (choose type below) <br /> a SOIL BORING # <br /> ELL # ItaS- I DOVER-BORE. DIAMETER <br /> Other G PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: Reference : Acs-prepared soil vapor Rr on/xn-situ Air Sparging Pilot study Work Pian, dated 23 no„e�aer a <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> B MONITORING %RHOLLOW STEM DIA. OF BOREHOLE 8 " B MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA: 2 " <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL g PVC Q OTHER: <br /> B VAPOR B MUD ROTARY DEPTH OF GROUT SEAL 17 ' TREMIE TYPE TO BE USED: J .WAUGERS a HOSE <br /> �JWR SPARGE/ OZONE a PUSH POINT (GP or CPT) GROUT SEAL PUMPED: B Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> I] SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Tune I / I I Neat Cement <br /> Q OTHER: g OTHERAPPROX. BORING DEPTH 251 0 BOLTED TRAFFIC BOX or B STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: x s-prepared Soil vapor Extraction/in-situ Sir spargt„g Pilot study Work Penn, dated 23 WOVeMber 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/Companyvice President / Advanced GeoEnvironm nt 1 Inc . <br /> Print Name Robert ty Date 06 April 2010 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : 57 k"%_ % a, r,,, nwv <br /> WORK PLAN DATED: <br /> � kt L� nal <br /> 1 <br /> Application Accepted By -' jx- AAt 01 W Date Issued Q I o Areaf <br /> Grout Inspection By Date Final Inspection B _ DateS ` l'� La <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> 3>n 12 1 , vo <br /> sv > s 4 >. ov A3 vow 3cR k G1 tSl jJ SR# $ � � <br /> -57 Letter of Authorization to sign permit Encroachment doc <br /> C-57� WC ✓ -WAIVER_ C _ <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />