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o.- ...r San Joaquin County <br /> Environmental Health Department o SITE <br /> R `� { 600 East.Main Street Stockton CA 95202-3029� [��] <br /> : g 11J/ MIATION <br /> (209)468-3449 Fax: (209)46$-3433 Web: www.sjgov.org/eT IV I <br /> JUL. 2 6 ZD� i <br /> Well Permit Application yyr�l1pJ nA'�7 HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS VF`[IUWEN I{{HEr LTH � <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. fAW-viiGs8n compliance with San <br /> Joaquin n CountyDevelopment Title,Chapter 9-1115.3 and the Standards of San Joaquin County ty Entir nm <br /> o ental Health Department. <br /> Assessors <br /> WELLLocation 2402 Pacific Avenue Cross Street Castle St. City Stockton Zip 95204 Parcel# 125-060-01 <br /> PROPERTY van De Pol Enterprises, Inc. <br /> Owner c/o. David Atwater Address P.O. Box 1107 CIty Stockton Zip 95201 Phone# (209)465-3421 <br /> C-57 Contractor Gregg Dri 1 ling Address 950 Howe Road City Martinez Zip 94553 Lic#485165 Phone# - 0 <br /> Advanced <br /> Consultant I Sub Cntr GeoEnvironmental, Inc.Address 837 Shaw Road City -r-1006StocktonLic# 680227 Phone# (209)46 , <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 'NEW WELL 1 BORING (CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> )nOILBORING# B-1� 5-12, B-13 T QOVER-BORE. DIAMETER <br /> $Wr=LL# VW-8, VW-9, VW-10 7 Q PRESSURE GROUT ; <br /> Q*Other GROUT SPECIFICATIONS - <br /> COMMENTS: Reference AGE-prepared Work Plan Addend um-February 2009, dated 10 Februar 2010 <br /> i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> u <br /> Q MONITORING OLLOW STEM DIA:OF BOREHOLE gw - Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL VVC Q OTHER: c' € <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 14' 1 ' TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE,PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> XSOIL BORING Q HAND AUGER GROUT SPECIFICATIONS e. 1111 4I d k <br /> Q OTHER: li OTHER APPROX.BORING DEPTH W OLTED TRAFFIC BOX or Q STOVE PIPE ° <br /> CONDUCTOR CASING PROPOSED NIA (if YES,list specifications in comment section) <br /> COMMENTS: Reference AGE-1prepared Work Plan Addendum-February 2009, dated 10 Februar 2010 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x TiflelCompanyvice President Advanced eoEnvironmental Inc. <br /> Print Name . Robert E.`Mart Date ('Ju <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: QP 2 2" L <br /> WORK PLAN DATED: - +� `L` Ste- M2 <br /> Application Accepted By Date Issued 2$ J Area 3G ! <br /> Grout Inspection By Date Final Inspection By Date 7(� <br /> f Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# - FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> So .nD , .aJ 3f ''l 2 �{c7 SR# p��c7 r <br /> i C-57✓✓ WC -WATVERk_ C-57 Letter of Authorization to sign permit-L"' Encroachment.doc— <br /> EHD29.02-001 UVEB. <br /> 9/11/2007 <br />