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San Joaquin County <br />Environmental Health Department SITE <br />600 E. Main Street, Stockton, CA 95202-3029n EC1 #1�11TIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd 11 'UNIT IV <br />Well Permit Application FEB 2 s 2608 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDENORONkir <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. ThMMq?licatio}j i§ Ynfa 4rnpliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental He`aitli'OepattMerlfi / <br />,'1p�6 EAST FREMONT ST WATTS ST STOCKTON 95205 Asse�sors153-130-0 <br />WELL Location Cross Street City Zip Parcel# <br />PROPERTY FREMONT PLAZA <br />Owner INVESTMENTS LP Address 2050 EAST FREMONT ST CitySTOCKTON Zip 95205 Phone# (209) 931-7070 <br />C-57 Contractor <br />TEST AMERICA Address 3195 LUYUNG DRIVE City RANCHO Zip 95742 Lic# 819548 Phone# (916)638-5564 <br />ORD <br />AA Lic# Phone# <br />ADVANCED GEOENVIRONM 837 SHAW ROAD C <br />Consultant/ Sub Cntr �i�t�s City tyS OCKTON 680227 (209) 467-1006 <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: N <br />ANEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />1:,WELL # M W — 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />FEE INFO <br />MONITORING <br />)THOLLOW STEM <br />DIA. OF BOREHOLE 8 ° 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ 2" <br />DATE PERMIT / SERVICE REQUEST # <br />0 EXTRACTION <br />AIR HAMMER/DRIVEN <br />CASING THICKNESS SCH 40 TYPE OF CASING: 0 STEEL JPVC 0 OTHER: <br />34s3.ov <br />0 VAPOR <br />MUD ROTARY <br />DEPTH OF GROUT SEAL 36' TREMIE TYPE TO BE USED: [[AUGERS 0 HOSE <br />�) <br />0 AIR SPARGE/ <br />OZONE 0 PUSH POINT (GP or CPT)GROUT <br />SEAL PUMPED: 0 Yes IjYQo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS TYPE II NEAT CEMENT ( PORTLAND) <br />0 OTHER: <br />_0 OTHER <br />APPROX. BORING DEPTH 55' D; BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />MW -19 <br />CONDUCTOR CASING PROPOSED NO (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: <br />OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that I have p, epared this application and that the work will be done in accordance with San Joaquin <br />County Orrofi, a c RUIe. .nd Regulations, and all applicable California State Laws. <br />Signed x 1 Title/Company EVANCED GEOENVIRONMENTAL, INC <br />Print Name ARTHUR DEICKE Date 05 NOVEMBER 2007 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS:�4 <br />WORK PLAN DATED: I l o <br />Application Accepted By Date Issued 3 A O Area <br />Grout Inspection By Date 17-jg42 % Final Inspection By a Date O <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# FAC# DEQ <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />3501A <br />3So� <br />g4lc;oo4s <br />$f-zgy.oc <br />34s3.ov <br />2�vit <br />3 `(fSR# <br />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001 web <br />6/22/04 <br />