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. .,o SAN JOAQUIN COUNTY 0. <br /> ENVIRONMENTAL HEALTH DEPARTMEN+ u �E�" <br /> 600 East Main Street, Stockton, CA 95202-3029 � SN`eo O`1 r1 0166 GIATION <br /> w <br /> 4 P Telephone:(209)468-3454 Fax:(209)468-3433 Web:ww .siaov.oY MKd' UNIT IV <br /> GfF01t <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or 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. <br /> pp I �l Assessor's <br /> Well Location 4126 E.Main St—51 1 et.-6.I,�- Cross Street Om/AAnA(Xi/,/e L f City Stocklon CA Zip 95215-6726 Parcel# lrizoaoz <br /> Property /�II <br /> Owner SSC (2-Ij I C W 0r)z 5 Address 1 8 f�f-RZef b'^ City sacktcn DA Zip ciSSI Phone* <br /> C-57 Contractor Precision Sampling Inc(PSI) Address 2365 Wigwam Dr. City Stockton CA Zip 95205 LIC# 636387 Phone <br /> ConsultanUSub Cntr ATC Associates Address 1117 Lone Palm Ave.Suite 201 City Modesto,CA LIC# Phone (209)579-221 <br /> GIS Coordinates:X 37254068 Y -121233654 ,Township T1N Range R7E Section Secs <br /> WORK TO BE PERFORMED: <br /> N NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) [I DESTRUCTION(CHOOSE TYPE BELOW) <br /> [I SOIL BORING# ❑OVER-BORE DIAMETER <br /> ©WELL# Nwnc('c'm —") [:1 PRESSURE GROUT <br /> ❑"OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS:See ATC Wkpins Supplemental Subsurface Investigation Work Plan dated 2/27/2009 and Interim Remediation Implementidw Work Plan dated 3/62009 appmved by Lod Dunwn <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> N MONITORING ©HOLLOW STEM DIA.OF BOREHOLE 8 inch ❑MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS PVC Schd 40 TYPE OF CASING:❑STEEL OO PVC ❑ OTHER None <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS 0 HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:0 Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING EHAND AUGER H.MDleartofivafeel GROUT SPECIFICATIONS Neateement <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list speeltiw9ons in comment s on) <br /> COMMENTS:n«ua wm e.ae..nma u.ire.mww.km.�o<..wmwa wa,b�.acpn aww��"a�•N Ifo f.x bp..n a po.��xx+ce m m.:awaix�.rvom n4,ze a.rn.o se..,. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby c ify that I have pre red this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Re ulatio s,a/t��d Ilapp c e dorni ws. <br /> Title/Company ATCAssodales <br /> Print Name Michael D.Sores Date February 18,2009 <br /> ,. <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �O }� #^a t tA S7i-�f <br /> WORK PLAN DATED: 2'2'}•03 M'V t 4!�to— ' <br /> APPLICATION ACCEPTED BY (A A A n rCr DATE ISSUED_-SJ2.q 10 AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE tl a3/�v <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# I INVOICE <br /> 36-03 J$W,0o o6`1g2� 3 zY to SR# S9517-1 <br /> C-57 <br /> 5 7— <br /> C-57 . WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />