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Feb. 11 2010 12:59PM Adv nced Geo Environmental No. 6431 P. 2 <br /> 4 . 1 San Joaquin County ((�o�((� COPY <br /> Environmental Health Department tf LIEV� ��� 'V�fE <br /> 600 East Main Street, Stockton,CA 95202-3029TIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:Www.sjgov.org/ehd FEB 1 Z��UNIT IV <br /> 3 Well Permit Application ENVIRO��ppWENTHEALTH <br /> NON-REFUNDABLE PERMIT.EXPIRES 1 YEAR FROM DATE ISSUED PERMnay <br /> IT/SERVICES / /5 <br /> Applioatloh is hereby made to San Joaquin County for a permit to Construct and/or install the work descdhad. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 0-1115.3 and the Standards of San Joaquin County Environmental Health Department. P-Nw <br /> WELLLocation 601 East Main Stteet Assessors <br /> c"/�r/f.CrObb Stfeel AmeYican St City Stockton Zip 95202parcel#_ <br /> PROPF�'^r Address__(vim City QkkrlOYl Zlp�Phone# <br /> Ovmar <br /> d ced <br /> 0-57 Contract eo nvironmental, znc.Address 837 Shaw Road CityStockton Zip 95215 Lic#680227 Phone#(209)467-1006 <br /> Advanced <br /> Consultant/Sub Cntr 6agoE1nviironnmental, rne.Address.837 Shaw Road City Stockton Uc# 680227 Phone# (209)467-1006 <br /> GIS Coordinates:X JT- '0 ,Y �ZI. } .Township Range Section <br /> WORK TO BE PERFORMED: <br /> %NEW WELL/BORING (E,EL GEOPROBE,HYDROPUNCH,HAND-AUGF.R,OTHER") 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 1R.3 u OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0'Other GROUT SPECIFICATIONS <br /> COMMENTS: _ C <br /> TYPE OK WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS h <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF eOREHOLE?" a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: \fe <br /> 0 EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: p STEEL 0 PVC p OTHER: l <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Max. 40' TREMIE TYPE TO BE USED: p AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE*PUSH POINT GP r CPT)GROUT SEAL PUMPED: BLYes p No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL 80RING aHAND AUGER GROUT SPECIFICATIONS Type 1/II Portland Neat Cement <br /> p OTHER:_0 OTHER APPROX.BORING DEPTH Max• 40, a BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications In comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. r <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I 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 /> SignedX . ,Title/CompanInc. <br /> Print Name Robert E. Marty Dale 16 February 2010 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,A /V0 G(jf- N <br /> WORK PLAN DATED: —22- - /O j—L(c-ZofO <br /> Application Accepted ByDate issued — <br /> Grout Inspection By Date U Final Inspection By Date r i <br /> Destruction Inspection By fDate <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REVD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> sR# <br /> C-57 WC=WAIVER-__,_ C-57 Letter of Authorization to sign permit Encroachment do4gjq L <br /> EHD29-0WEB <br /> 9!11120071 FILE COPY <br />