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San Joaquin County uUr ' <br /> Environmental Health Department SITEE <br /> 600 East Main Street, Stockton, CA 95202-3029 SEP 1 0 2009 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.�rgleIbid <br /> OKENT HEALTH UNIT IV <br /> c o N`" Well Permit Application I�VP�IERMIT,/SERVIC <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor 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.Assessors <br /> March Lane Cil Stockton Zip 95207 Pamel# 108-160-01 <br /> WELL Location 5151 Pacific Avenue Cross Street Y <br /> PROPERTY San Joaquin 95207 phone# 209-938-7554 <br /> Owner ^=eta College Address 5151 Pacific Avenue City Stockton Zip <br /> Advanced Stockton Zi 95207 Lic#680227 phone# (209)467-1006 <br /> C-57 Contractors a n ntal. Inc.Adtlress 837 Shaw Road City P <br /> Advanced <br /> Inc. Address 837 Shaw Road Cify Stockton Lic# 680227 Phone# (209)467-100 <br /> Consultant/Sub Cntr GeoEnvironmental, <br /> _ y�u. ,Township Range Section <br /> GIS Coordinates:X ■ _ <br /> WORK TO BE PERFORMED: <br /> 8 NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) D DESTRUCTION (choose type below) <br /> 8 SOIL BORING# Bl through B19 D OVER-BORE. DIAMETER <br /> WELL# D PRESSURE GROUT <br /> B GROUT SPECIFICATIONS <br /> a-Other <br /> COMMENTS: Reference AGE-prepared Limited Subsurface Site Assessment Work Plan, dated 10 September 2009 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLEI�25"D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: x/n <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER' <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL max 20' TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE/OZONE R PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> K SOIL BORING aHAND AUGER GROUT SPECIFICATIONS Tvoe I/II neat cement - <br /> D OTHER: D OTHER APPROX.BORING DEPTH max 20' D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (if YES,list specifications in comment section) <br /> COMMENTS:Reference AGE prep zed Limited Subsurface Site Assessment Work Plan, dated 10 September 2009 r, <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. j <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. tt <br /> 1 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 z_-f�/� Title/Company V'ce President/Advanced GeoEnvironmental Inc <br /> -1 Date 10 SEPTEMBER 2009 <br /> Print Name Robert E. rtv -- ` <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Sa ✓d�'�T"' <br /> WORK PLAN DATED: <br /> Application Accepted ByDale Issued Aregq <br /> Grout Inspection By Date 'o Final Inspection By fi'� <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> "ACCOUNTING AID# FAC# <br /> AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> Sot b _� sR#_ AIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EFID 29A2-001 WEB � <br /> FILE COP Y °" <br /> 9/11/2007 <br />