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NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS 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 Regulations, and all apnlica/ble/C/alifornia Laws. Signed A l/G�.t'/�� Title/Company Project Geologist, Herst & Associates, Inc. Print Name David A. Vasbinder Date Z DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE, ADDRESS: WORK PLAN DATED: � APPLICATION ACCEPTED BY ��W DATE ISSUED AREA �y GROUT INSPECTION BY FINAL INSPECTION BY�� DATE I I vZ I Lp DESTRUCTION INSPECTION DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO SAN JOAQUIN COUNTY -' ENVIRONMENTAL HEALTH DEPARTMENT INVOICE 600 East Main Street, Stockton, CA 95202-3029j� i Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.org/ehd .. a �P ((EPIP V NIT 0 WELL PERMIT APPLICATIONSAN-JOAQU/N ENVIRq COUNTY NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED HEA�iWD V21 �gk�,T.1' 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 �C1M San Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. Assessor's Stockton 181-150-11 Well Location ^/in 1500' West of Austin Road Cross Street Austin Road City Zip 95215 Parcel # Property State of California, Department of Juvenile Owner Justice Address 7650 S. Newcastle Road City Stockton Zip 95213 Phone # 209-944-6327 209-465-8712 C-57 Contractor Precision Sampling, Inc Address 2365 Wigwam Drive City Stockton Zip 95205 Llc # 636387 Phone Consultant/Sub Cntr Herst & Associates, Inc. Address 4630 S. Hwy 94 - N. Outer Rd. City Sl. Charles LIC # Phone 636-939-9111 GIS Coordinates: X s3sz7sa.sa Y 2148813.32 Township 1 North Range 7 East Section 34 WORK TO BE PERFORMED: m NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) ❑ DESTRUCTION (CHOOSE TYPE BELOW) ❑ SOIL BORING# ❑ OVER -BORE DIAMETER IZI WELL # AMW-23 ❑ PRESSURE GROUT ❑ *OTHER GROUT SPECIFICATIONS COMMENTS: TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS m MONITORING [IHOLLOW STEM DIA. OF BOREHOLE 8 -inch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 2 -inch ❑ EXTRACTION ❑ AIR HAMMER/DRIVEN CASING THICKNESS Sch 40 TYPE OF CASING: ❑ STEEL m PVC ❑ OTHER ❑ VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 0-149 TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ AIR SPARGE/OZONE ❑ PUSH POINT (GP OR CPT) GROUT SEAL PUMPED: la Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) ❑ SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS 7 x 94# Portland cement : 100 gal. water ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 175 ❑ BOLTED TRAFFIC BOX OR 0 STOVE PIPE CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS 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 Regulations, and all apnlica/ble/C/alifornia Laws. Signed A l/G�.t'/�� Title/Company Project Geologist, Herst & Associates, Inc. Print Name David A. Vasbinder Date Z DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE, ADDRESS: WORK PLAN DATED: � APPLICATION ACCEPTED BY ��W DATE ISSUED AREA �y GROUT INSPECTION BY FINAL INSPECTION BY�� DATE I I vZ I Lp DESTRUCTION INSPECTION DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE PERMIT/SERVICE # INVOICE 1 S G- 4 SAI 6 9 S R#W " "- C-57 WC -WAIVER I C57 LETTER OF AUTHORIZATION TO SIGN FERMI I EHD 29-01 11/5/07 ENCRUAUHMEN I UUIJ WELL PERMIT APP