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Lr! - <br /> Oa,n Joaquin County <br /> Fnvl.ranrnental Health Department PAYMF-NT <br /> 600 East Ma'h Street, StOckton; CA 95202-3029 RECEIVED SITE <br /> ` (249)468-3449 Fax: 209 46$-3433 Web.-www.s' ov,or e y 2 g 1 <br /> ( � � a� � � ntllrlArlonl <br /> Well POrmit Application sa�NOlAOP4rAs=NTaL <br /> UNITIV f <br /> NON-REFUNDA13LE PERMIT E)CPIRES 1 YEAR FROM GATE 13$UEbH �UE;q <br /> Appllodticn is hereby mage to San Joaquin County for a permit t4 construct andlor Install the tN4ric described• <br /> Joaquin County Development Tiller Chapter <br /> 8'I T •e and the standards of San Joaquin County Environmental HeerThis t fDepaKmen Silo rn compliance with Sar? <br /> WELL I.acatlon ,2830 West: Fremont 5tx'eet Cress$trees San Juan Ave . <br /> FROPEf�TY City .9t4cktron ASSessoes <br /> Z'P 95 �Parce4 233-360-33 <br /> Owner john McDaniel Address 1930 W Fremont St <br /> All Well City St4ckto jp 9S2113 phone# (209) 839-25[)l <br /> C-57 Contractor Abandonment Address 662fi Merchandise Wa Diamond <br /> va Ce Y City-EE ir1 ' Zip 95619UC4 84359 <br /> Cansulfant/$uh Cntr GeoEnvironmpental Phdne# 534 644 1)-9 <br /> Address 837 Shaw ROad City StaaktQn <br /> GI$Coordinates: Lic# 680`22 I Phone#ter py)467- 046 I <br /> Y ,Township I <br /> @I4 T{?19E PE Range <br /> he^-��Section 1 <br /> Q NEW WELL/BQRING (� GEOPROBE,HYDROPUNCH,BAND-AUGER,OTHER <br /> Q SOIL BARING# 19 DESTR4ICTION (choose type below) <br /> a*Ocher 1 <br /> WELL# S OVER-BORE. DIAMETER 8-20�4rehole <br /> Q*Other Q PRESSURE GROUT <br /> COMMENTS; Wells to be destro ed: MW $nil mw-3GROUT SPECIFICATIONS-T2 TI ,Portland <br /> 1YpE OF WEWEu IN Td TON p <br /> Ca�+rS <br /> 0 MONITORING 7BUCT14N sPECIFICATIONs_ <br /> �HOLI.OIIUSTEM DIA.OF I30REH0� <br /> Q EXTRACTION a AIR HAMMEEZ/DRIVEN E ©MULTIPLE CASINGS n MULTI-LEVELVE! MLL CASING DIA; <br /> CASING THICjWES�e <br /> a VAPOR 11 MUD ROTARY n`pE OF CASING,; 11 STEEL a PVC p OTHER.�^ <br /> (]AIR SPARGE/OZONE 0 PUSH POINT(GP Or CPT)GROUT HOSE <br /> $EALOF RPUMpEp; ~~OUT SEAL Tf2EMIE TYPE T(}j3E,USED: <br /> QYes p No (NOTE: MAJLIMtJM FREE-FALL DEPTH 1$30') <br /> D SOIL BORING f]HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER; OTHER <br /> ]C_BORING DEPTH <br /> CONDUCTOR II BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS, CASING PROPQSED <br /> - �(If YES,list speclfroatfons in comment section) <br /> NOTE; OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR LNCROAC t <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. HMENT PERMITS. <br /> I hereby certify that I have prepared this application and that t <br /> County Ordl cos uI he work Will be done In accordance with San- <br /> d RegUlations,and all applicable California State Laws. .Joaquin <br /> Signer!x <br /> TidedtromRanyViet P; dEd ident Advanced GeoEnvironmental Inc. <br /> Print Nam obert E. Marty <br /> oats V <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1q --5C;' <br /> WORK PIAN DATED: 'Ilk <br /> AppllCation Accepted Fay <br /> Grout InapecUon By Date Issued_ e5 -1 Area��� <br /> Date <br /> Date Fnal Inspection By -r--'--..__..�..... <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK* REC'rl 13Y DATE PERMIT I SERVICE REQUEST# INVOICE <br /> t SR# <br /> 1 62t: lf ( (0fl Z74 <br /> 657Z- WC -WAIVER C-•57 Letter of Authorization to sign permitsEncroachment docz e <br /> EUD Z9-02-001 WEB -- C <br /> 911 112007 <br /> I <br />