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! San Joaquin County <br /> ..o — <br /> " ? Environmental Health Department HIE( I E <br /> K 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> ' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd �tlN 1 7 c01 INIT IV <br /> � P ENVIR0NR?ENTlEAL"' <br /> Well Permit Application rr- <br /> PERMIT/SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 7 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 /> City of Stockton Right of Way 135 East Miner Ave Assessors <br /> WELL Location Cross Street Hunter City Stockton Zip 95202 Parcel# 139-080-10 <br /> PROPERTY <br /> Owner BT. SOHN'B BP1s JOPAr, clo c8 Address 316 N. E1 Dorado St. City Stockton Zip 95202Phone# (209) 466-5311 <br /> ALL WELL AS <br /> - SLAGLE 3809 Pleasant Valley Rd Placerville 85667 #848359 1 800 948-1355 <br /> C-57 Contractor Address City Zip Lic# Phone# <br /> 95215 <br /> Consultant/Sub Cnt�' n <br /> dvaced GeoHnvironmental Stockton Address City Lic# Phone#837 Shaw Rd. Stkt680227 209-467-1006 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> g NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) E DESTRUCTION (choose type below) <br /> O SOIL BORING <br /> O m # OIUMETER <br /> rw-la, MW-2B,M -3B,MW-4B PRESSURE GROUT <br /> *Other GROUT <br /> SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 141 MONITORING x0 HOLLOW STEM DIA.OF BOREHOLES�25" 0 MULTIPLE CASINGS [[MULTI-LEVEL WELL CASING DIA: -__-_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 'tl PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL GO' TREMIE TYPE TO BE USED: )GAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Tyg /TT <br /> 0 OTHER: O OTHER APPROX.BORING DEPTH 60' O BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: mw-i th h MW-5 will b located the sidewalks h k 1 , Monitoring well Installation Work Plan 12/03/2008. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Orr3' O/diinaances, Rules atld Regulations,and all applicable California State Laws. <br /> Signed L/ I Title/Company Geologist/Advanced GeoEnvironmental. Inc. <br /> Print Name William Little Date o6/i1;/01n <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADPR'ESS: 135- IVB L Al . <br /> WORK PLAN DATED: 12 13 I 03 <br /> Application Accepted Byttt--�YC4 ` Date Issued 3" Area <br /> Grout Inspection By 1,, Date Z Final Inspection By Date <br /> Destruction Inspection By Date ��77 " <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 35,03SR# 60006 <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit ✓ Encroachment doc x <br /> EHD 29-02-001 <br /> 6/22/04 <br />