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SAN JOAQUIN COUNTY . <br /> ECVWRONMENTAL HEALTH DEPARTMENT SITE <br /> �- 600 East Main Street, Stockton , CA 95202-3029 MITIGATION <br /> NUv'fev (209) 468-3454 Fax: (209) 468-3433 Web: wvnv.sigov.org/ehd UNIT IV <br /> �l1: OR <br /> ENVIRONMENT HEAGWELL PERMIT APPLICATION <br /> PERMITI MiWINDABLE 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 /> 6230 Assessors <br /> Well Location—� PACIFIC AVE Cross Street PORTER AVE City STOCKTON Zip 95207 parcel # 081- 360 - 03 <br /> Property STEVEN CANEPA 1536 N . HUNTER ST STOCKTON 95204 209 - 948 - 1636 <br /> Owner Address City Zip Phone # <br /> ADVANCED <br /> C-57 Contractor GEOEnVTPaNMFNTPAT Address 837 SHAW ROAD city STOCKTON Zip 95215 LIG # 680227 Phone <br /> ADVANCED GEOENVIRONMENTAL 837 SHAW ROAD STOCKTON 95215 209 -467 - 1006 <br /> Consultant/Sub Cntr Address City Lic # Phone <br /> CIS Coordinates: X , Y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELUBORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') El DESTRUCTION (CHOOSE TYPE BELOW) <br /> [$ SOIL BORING# V- 1 , V- 2 , V-3 , V- 4 , V- 5 , V- 6 ❑ OVER-BORE DIAMETER <br /> ❑ WELL # ❑ PRESSURE GROUT <br /> [] *OTHER GROUT SPECIFICATIONS <br /> ❑ EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM DIA.. OF BOREHOLE 1 . 5 " ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br /> ❑ EXTRACTION ❑ AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br /> ❑ VAPOR- - -- ❑ MUD ROTARY DEPTH OF GROUT SEAL. SFC TO TDTREMIE TYPE TO BE USED :AUGERS El HOSE - - <br /> ❑ AIR SPARGE1020NE 9 PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: ❑ Yes ❑ No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> t3SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS PORTLAND NEAT CEMENT TYPE I / II <br /> ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 5 FT AND 30 Frf, BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Co YES,.Iisl spedficatlons In comment section) <br /> COMMENTS: V- 1 THRU V-5 TO BE ADVANCED TO 5 FT , WHILE V- 6 TO. BE �APPROX 30 FT <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, a alfa licabl Ilfornla Laws, <br /> Signed Title/Company ADVANCED GEOENVIRONMENTAL , INC <br /> Print Name RO ERT MARTY Dale 09 NOVEMBER 2009 <br /> DE,PPAR/T�MENgT USE ONLY - <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Q 1023 / 4zI �Y-I ke <br /> WORK PLAN DATED: /0/8/d/ <br /> r i � / <br /> APPLICATION ACCEPTED BY /IUC71 DATE ISSUED 11 1.P OJ AREA /y47 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID # FAC # <br /> PE CODES FEE INFO AMT REMITTED CHECK * RECV'D BY DATE PERMIT/SERVICE # INVOICE <br /> as° / .,ys �/3'/ °� 3033 SR# 00 58763 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-Di 10/28/09 WELL PERMIT APP <br />