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�0 4u'NRECEDDQo San Joaquin County JUN j <br /> y i{ Environmental Health Department 20 91TE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 EM/1pjUfui�-VM4#TION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd PERMIT/9ERVQNIT IV <br /> Well Permit Application rot ron <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED FILL UU" <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 /> Assessors <br /> WELL Location 4407 East Waterloo Road Cross Street Piccoli CityStockton Zip 95215 Parcel# 087-100-059 <br /> PROPERTY 4407 East Waterloo Road <br /> OwnerErnest P. Giannecchini Address City Stockton Zip 95215 phone# (209) -931-2850 <br /> C-57 ContractorAdvanced GeoenvironmentalAddmss 837 Shaw Rd CityStockton Zip95215 LiC 680227 Phone#9) -467-1006 <br /> Consultant/Sub Cntr Ad..anced aeoenoaronmentalAddress 837 Shaw Rd City Stockton Lic# Phone# (2og)467-loo6 <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') n DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 4 n OVER-BORE. DIAMETER <br /> 0 WELL# n PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS:Please refer to workplan dated 08 June 2010 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE1_25"n MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA: N/A <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS N/A TYPE OF CASING: n STEEL n PVC 0 OTHER: N/A <br /> 0 VAPOR n MUD ROTARY DEPTH OF GROUT SEAL N/A TREMIE TYPE TO BE USED: n AUGERS n HOSE <br /> p AIR SPARGE/OZONE it PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING n HAND AUGER GROUT SPECIFICATIONS Portland Cement <br /> g OTHER: n OTHER APPROX.BORING DEPTH 5 feet n BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (if YES,list specifications in comment section) <br /> COMMENTS: Please refer to CVRWQCB approval letter dating 14 June 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 Ory les Regulations, and all applicable California State Laws. <br /> Signedx Title/Company Project Scientist <br /> Print Name Axt Deicke Date 12 June 2010 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 9 LID }k)py�j�l rrs — 12661 (GAIgL &c,,A 21> <br /> WORK PLAN DATED: 6I g Po <br /> Application Accepted By [ASM 44LLC= — Date Issued_ 6 I/ FSI/ Area <br /> Grout Inspection By jne_ Fro-ne.q Date r -30-/o Final Inspection By Vj�f , mWh ate 6 -30 -10 <br /> Destruction Inspection By Jj CIC.a m0�yp}yl,e,vl Date & -30 /6 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> -7okc7Y $Arno 3\ z10 6 /x�io SR# bD? <br /> C-57✓ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />