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—Ufk <br /> Aq Co SAN JOAQUIN COUNTY %%00 <br /> _ VIRONMENTAL HEALTH DEPARTMENT <br /> E1 SITE <br /> 00 East Main Street Stockton, CA 95202-3029 MITIGATION <br /> ele fi ( ) - an:( ) - e :www.sigov.orgeh <br /> ���v e: 2094683449 F2094683433 Wbwww.sigov.org/��e� UNIT IV <br /> �;�y�ALTH WELL PERMIT APPLICATION <br /> PER��1lT SEP A4'-�EFUNDABLE 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 /> Assessor's <br /> Well Location 15406 South Tracy Boulevard Cross Street crimes Road City Stockton Zip 95206 Parcel# 189-170-07 <br /> Property <br /> Owner YAMADA BROS Address same as above City Stockton Zip 95206 Phone# 209-483-8635 <br /> C-57 Contractor Ad"anced GeoEnvironmental Address 837 Shaw Road City Stockton Zip 95215 LiC# 680,727 Phone <br /> Consultant(Sub Cntr same as above Address City Lic# Phone <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ®NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ®SOIL BORING# B6, B7, BS _ ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE 2° ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 10-351 TREMIE TYPE TO BE USED®AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ®PUSH POINT(GP OR CPT)GP GROUT SEAL PUMPED:®Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> El SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Portland Type II <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 10-35, ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (a YES,list specifications in comment section) <br /> COMMENTS: <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 ppll able liiogrnniia Laws. <br /> Signed / yt Title/Company Project Scientist/Advanced GeoEnvironmental <br /> Print Name Ally Colavita Date 05/11/10 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: d ro S, 7 I <br /> WORK PLAN DATED: 912:1_ O Q <br /> APPLICATION ACCEPTED BY ( DATE ISSUED ® 1D AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DAT 1�Y (o <br /> DESTRUCTION INSPECTION BYDATE <br /> COMMENTSICONDITIONS: k019 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 3s01 8C1 - 8l - 5/1 ZI 10 SR#005�3 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 1115107 WELL PERMIT APP <br />