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aryg San Joaquin County 00118 <br /> EnN. inmental Health Department. SITE <br /> 600 E.Main Street, Stockton CA 95202-3029 (Dj � ON <br /> 70 (209)468-3449 Fax. (209)468-3433 Web: www.sjgov org/ehd �l]l lJ v <br /> r v Well Permit Application APR-1.4 20OR- <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 applica(l FRWW fflRM6@8nce with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaqulr County Environmental Health Department. <br /> 9504 SOUTH HARLAN ROAD WEST LYNN WAY FRENCH CAMP Assessors <br /> WELL Location Cross Street,., _ . ._Ctty .Zip_95231 --_Parcel#_ 153 210-C2 <br /> PROPERTY AON CENTER �— <br /> Owner CONTIGROUPAddress200 ADLPH. STE 19oc CITY CHICAGO, ""Zip 60601 phoir 312-381 7178 <br /> C-67 Contractor CASCADE DRILLING. INC Address 3632 OMEC CIRCLECilys"'Ncao conoovrZip 95742 Li 717510 phone# 916 638.1169 <br /> .. ....._ _._... <br /> Consultant lSubCAA VANCED GEO ENVIRONMENT 637 SHAW ROAD STOCKTON 680227 209 46'7 1006 <br /> Nddress CIIY_._. Lic#,_..__., Phone#_ <br /> GIS Coordinates:.X Y _ Township_ _ _Range_.. Section <br /> WORK TO BE PERFORMED: <br /> a NEW WELL i BORING (CPT.GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) a DESTRUCTION (choose type below) <br /> 0 SOIL BORING#­ D OVER-BORE DIAMETER <br /> 1NdELL# MW 13H,EW-11B,EW__ 12B,IW-BH1,IW-BH2A a PRESSURE GROUT <br /> a*Other _ ._ GROUT SPECIFICATIONS _ <br /> COMMENTS.MW• MONITORING WELL//EW• EXTRACTION WELL//IW: INJECTION WELL <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )gNONITORING WOLLOW STEM DIA.OF BOREHOLE88"�12"a MULTIPLE CASINGS a MLLTl-LEVEL WELL CASING DIA._2"(6" <br /> $)EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS SCHED 80 TYPE OF CASING: U STEEL XU PVC a OTHER: -- <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 56'/61, TREMIE TYPE TO BE USED: ff AUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> U SOIL BORING a HAND AUGER GROUT SPECIFICATIONS TYPE II NEAT CEMENT (PORTLAND) <br /> TOTHER INJECTION a OTHER APPROX.BORING DEPTH 801/85' a)BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (if YES,list specifications in comment section) <br /> COMMENTS: IW-BHI/IW BH2A: 6"CASE/12"13OREHOLE/TD:80FT/SEAL:56'//MW-13B: 2"CASE/8"BOREHOLE/TD:8OFT/SEAL .56F7 <br /> EW-11B/EW 12B: 6"CASE/12"BOREHOLE/TD:85FT/SEAL:61' Se-Tf-•YW6tR;T.Q t - A0 qrawl". Wntj C-40., <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHNANT PERMITS, <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordindhces Rules and Regulat(gns; and all applicable California State Laws. <br /> Signed X [ Title/Company ADVANCED GEOENVIRONMENTAL, INC <br /> Print Name ROBERT`--E MARTY _Date 14 APRIL 2008 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: `l,'cl jo QoA Fnsi > C`r: e-� <br /> , v,. 4N <br /> WORK PLAN DATED:_ Z-11 to K <br /> Application Accepted By 1 l�c CA i Date Issued �' �'_ Area e5ev <br /> Grout Inspection By Date Final Inspection By Date <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 /> no ?-7-3,4L SR# 5 p 8" <br /> C-57_ WC_ WAIVER_ C-57 Letter of Authorization to sign permit li Encroachment doc_ <br /> EHD 29-02-00Iweb <br /> 622/04 <br />