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SAN JOAQUIN COUNTY Ft6CEIVE <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029,1U1 18 2012 MITIGATION <br /> ,. Telephone: (209)468-3449 Fax: (209) 468-3433 Web:www.sagov.org/ehd UNIT IV <br /> ENVIRONMENTAL HEALTH <br /> WELL PERMIT APPLICATION PERMIT/SERVICES <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$5tanndards f an J a ui County Environmental Health Department. <br /> i A er�DA- �0 Stockton Assessor's <br /> Well Location 24 ark Street Cross Street City Zip 95203 Parcel# 139-060-35 <br /> Property <br /> Owner Canepa Carwash Park Address 1536 North Hunter St. City Stockton Zip95204 Phone#1-209-948-1636 <br /> C-57Contractor All Well Abandonn ess9245 Beatty Dr. Suite A City Sacramento Lic# 848359 Phone 1-916-363-WELL <br /> A vanced GeoEnvrionmental Inc. <br /> Consultant/SubCntr Address 837 Shaw Road City Stockton Lic# NA Phone 1-209-467-1006 <br /> GIS Coordinates:X -Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> R NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER') ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> [:I SOIL BORING# ❑OVER-BORE DIAMETER <br /> ©WELL# DPE-2,3,4 ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> COMMENTS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ®MONITORING ®HOLLOW STEM DIA,OF BOREHOLE 10 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:4 <br /> ®EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS N/A TYPE OF CASING:❑STEEL ®PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL Variable TREMIE TYPE TO BE USED®AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:®Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Portland Cement <br /> ❑OTHER El OTHER: ft. bsg OTHER: APPROX.BORING DEPTH ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. / /I <br /> Signed IN`k",l Title/Company <br /> Print Name Lti> L 7 _ Date 07 IJ 6, / 7, <br /> EPART ENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2 7q � A <br /> WORK PLAN DATED: CH-ki 9 2o i Z <br /> APPLICATLLON ACCE ED BY DAT SSU2_4i!Z AREA 9q7 <br /> , <br /> GROUT INSPECTION BY// �. FINAL INSPECTI B 1.11 DATE <br /> DESTRUCTION INSPECTION BY �✓ a <br /> DATE <br /> COMMENTS/CONDITIONS: C_3—�, -� �i�.S�a T� ,��� a� 3 5� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> SR#oohs <br /> C-57 —WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PER T ENCROACHMENT DOC <br /> EHD 29-01 1115/07(WEB) 11 WELL PERMIT APP <br /> 3503 3 7S 3?T- <br />