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op0.0'" c SAN JOAQUIN COUNTY <br />?, ENVIRONMENTAL HEALTH DEPARTMENT SITE <br />600 East Main Street, Stockton, CA 95202-3029 MIT <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sipov.orq/ehd �T <br />IVEC3 <br />WELL PERMIT APPLICATION tier, 3 0 2008 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOA <br />QUIN COUNTY <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 c6lJ8II[IfI )< <br />Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. LTH DEPARTMENT <br />in SE quadrant of NCYCC 2100' E of Assessor's <br />Well Location Newcastle Rd. Cross Street Newcastle Road City Stockton Zip 95215 Parcel # 181-150-02 <br />Property State of California, Department of Juvenile <br />Owner Justice Address 7650 S. Newcastle Road City Stockton Zip 95213 Phone # 209-944.6327 <br />209-465-8712 <br />C-57 Contractor Precision Sampling, Inc Address 2365 Wigwam Drive City Stockton Zip 95205 LIC # 636387 Phone <br />Consultant/Sub Cntr Herst & Associates, Inc. Address 4630 S. Hwy 94 - N. Outer Rd. City St. Charles LIC # Phone 636-939-9111 <br />GIS Coordinates: X 6361156.06 Y 2147896.47 Township 1 North Range 7 East Section 34 <br />WORK TO BE PERFORMED: <br />m NEW WELUBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ SOIL BORING# ❑ OVER -BORE DIAMETER <br />WELL # AMW-22 ❑ PRESSURE GROUT <br />❑ *OTHER GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />is MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE 8 -inch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 2 -inch <br />❑ EXTRACTION ❑ AIR HAMMER/DRIVEN CASING THICKNESS Sch 40 TYPE OF CASING: ❑ STEEL m PVC ❑ OTHER <br />❑ VAPOR JZ MUD ROTARY DEPTH OF GROUT SEAL 0-149 TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE <br />❑ AIR SPARGE/OZONE ❑ PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: JZ Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />❑ SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS 7 x 94# Portland cement: 100 gal, water <br />❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 175 ❑ BOLTED TRAFFIC BOX OR m STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if 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 />Regulation and all appl' abl alifornia Laws. <br />Signed �1Tr^t� Title/Company Project Geologist, Herst &Associates, Inc. <br />Print Name David A. Vasbinder Date 2zz S/ 0 r <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: ^ n n <br />APPLICATION ACCEPTED BY DATE ISSUED AREA <br />GROUT INSPECTION BY C\\� FINAL INSPECTION BY DATE <br />DESTRUCTION INSPECTION BY DATE / <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />PERMIT/SERVICE # <br />INVOICE <br />\Sb'7S <br />W-ts— <br />Y3a 6 <br />SR _ <br />C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br />EHD 29-01 11/5/07 <br />ENCROACHMENT DOC <br />WELL PERMIT APP <br />