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0o an Joaquin County <br /> Envirmental Health Department • SITE <br /> D <br /> 600 E. Main Street, Stockton, CA 95202-3029 (�' ON <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/chd U <br /> T 0 "� Well Permit Application APR 1 Z =8 <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 applicaPffi fiT4E* 10C8nce with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 9504 SOUTH HARLAN ROAD WEST LYNN WAY FRENCH CAMP Assessors <br /> WELL Location Cross Street City Zip 95231 Parcel# 193-210-02 <br /> PROPERTV / <br /> Owner fYt t^c 11CbWr pA L/nA Address 1°030x9IL City r« Zip IrZY Phone# <br /> C-57 Contractor CASCADE DRILLING, INC Address 3632 OMEC CIRCLE CitY.! C co..0"Zip95742 Lic#717510 Phone# 916-638-1169 <br /> Consultant/Sub ClErVANCED GEO ENVIRONMENTAddress City Lic# Phone#837 SHAW ROAD STOCKTON 680227 209-467-1006 <br /> GIS Coordinates:X. ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> .U,WELL# MW-13B,EW-11B,EW-12B,IW-BHI,IW-BH2A 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS:MW: MONITORING WELL//EW: EXTRACTION WELL//IW: INJECTION WELL <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )DUONITORING gHOLLOW STEM DIA.OF BOREHOLE e"/12"p MULTIPLE CASINGS gMULTI-LEVEL WELL CASING DIA: 2"/6" <br /> $)EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCHED 80 TYPE OF CASING: 0 STEEL Xg PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 56'/61' TREMIE TYPE TO BE USED: O AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: X4Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS TYPE II NEAT CEMENT (PORTLAND) <br /> IFOTHER: INJECTION 0 OTHER APPROX.BORING DEPTH-80'/85' 0)BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (if YES, list specifications in comment section) <br /> // <br /> COMMENTS: IW-BHI/IW-BH2A: 6"CASE/12"BOREHOLE/TD:80FT/SEAL:56' MW-13B: 2"CASE/8"BOREHOLE/TD:80FT/SEAL 56FT <br /> EW-11B/EW-12B: 6"CASE/12"BOREHOLE/TD:85FT/SEAL:61' Se. l'{'CfA oo4 j r p{ BqroK <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I�haveprepared this application'and that the work will be done in accordance with San Joaquin <br /> County Ordi Oh a Rum nd Regulati a;a dill applicable California State Laws. <br /> Signed X Title/Company ADVANCED GEOENVIRONMENTAL, INC <br /> Print Name ROBERT'(81 MARTY Date 14 APRIL 2008 <br /> �. DEPARTMENT USE ONLY FILE CU" <br /> SITE MAP IN UNIT IV FILE, ADDRESS: `(S g LA yZ,�f 1 v.�,..� C Cct w <br /> WORK PLAN DATED: zff(Ofs <br /> Application Accepted By LNmtr�wv Date Issued 4IIS(o fl Area 6Z4 <br /> Grout Inspection By 1 Lawnnnrrv.* Date `I 2z ob' Final Inspection Byrm.t.ev.IDate__Y�2�/0� <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: S lti <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 26101 SR# �� p <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permitk-' Encroachment doc_ <br /> EHD 29-02-001web <br /> 6/22/04 <br />