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an Joaquin County <br /> fX. <br /> Environmental Health Department _ SITE <br /> I( . 304 Fast Weber Avenue, 3rd Floor, Stockton,CA 9'5202=i' ! �f 1 , r '1111111TlGATION <br /> r. -� I r <br /> {209)468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd I lev <br /> IkIlk <br /> Well Permit ApplicationIL Py <br /> fit R;l l i 7 <br /> NON-REFUNDABLE PERMIT EXPIRES 9 YEAR FROM DATE ISSUED i <br /> y <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work descr. _,,'T}iis), D,a,,I;, . made incompliance with San <br /> Joaquin County Development Title,Chapter and the Standards of San Joaquin County Environmental Hea7tK D'ep'artment. <br /> 2771 E.FRENCH CAMP ROAD 95336 Assessors ''77 J O 0 2. . <br /> WELL Location Cross Street City MA14TECA Zip Parcel# <br /> PROPERTY 2771 E. FRENCH CAMP RD '(209)992-5691 <br /> Owner DEAN JANSSEN Address City MANTECA Zip 95336 Phone# <br /> ADVANCED GEOENVIRONMENTAL 680227 (209).467-1006 <br /> C-67.Contractor Address 637 SHAW _RD. ___City STOCKTON Zip S2i�.Lic# Phone# <br /> ADVANCED GEOENVIRONMENTAL <br /> Consultant lSub Cntr Address 837 SHAW RD. CitySTOgKTON Lic# 660227 Phone#'(209)467-1006 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> II NEW WELL/BORING (CPT,GEOPROBE;HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose Type below) <br /> MSOIL BORING# SV-1, SV-2,SV-3 Q OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION'TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING ©HOLLOW STEM. DIA.OF BOREHOLE 1.25 110 MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA:___ <br /> EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:, p STEEL ©:PVC a OTHER: <br /> p VAPOR d MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS , n HOSE <br /> D AIR SPARGEI OZONE ft PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 11SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> .OTHER: 0 OTHER APPROX. BORING DEPTH 5' 0 BOLTED TRAFFIC BOX or 1]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: PLEASE REFER TO WORK PLAN DATED F BRIARY 27 2007- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS:AGREEMENT OR ENCROACHMENT PERMITS. <br /> 4$WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> II I hereby certify that l 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 -on", �+� Title/Company STAFF SCIENTIST <br /> Print Name_g3CKY_�,E _ Date 03-21-2007 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2-?71 ' F- -. rra n 1✓� Carn l,� ;,_-_ <br /> WORK PLAN DATED: Fe-6rl dg t24 117, 2 CO`I <br /> Application Accepted By Vi L+Dri t S` <br /> &_ __ d_�Y4-me-t, Date Issued 1 Z A 0 Area S <br /> Grout Inspection ByV i L�i r Date Final Inspection By V i A,,i 1 tqDate I0 7 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: f C r '� - I - <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED -CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 4 sa ( .oo SR# <br /> sa3 .o0 37.4-. 04 D SOOG <br /> C-57y WC___-_-WAIVER_. C-57 Letter of Authorization to sign permit_Encroachment doc` <br /> EFID 29-02-001 <br />€ 6127104 <br /> f _ <br /> s <br />