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Application Accepted By <br />Grout Inspection By Date It Final Inspection By <br />Date Issued / Area <br />Date 3 11210 g- <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.orgiehd <br />Well Permit Application FEB 1 <br />SITE <br />11 UNITIV <br />9 2008 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUECIPNviR oivkr, . <br />atj Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. TICErappficttO nUAinTdrjmpliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental I-1581th Dep eri/Cf7 r: <br />Assessors <br />WELL Location '-1 7- 14 East Waterloo Road Cross Street Therryland Ave City Stockton Zip 95215 Parcel# 1 0 1 - 021-32 <br />PROPERTY <br />Owner c hi.ef&fx IA kw b"cfc_ Address 6 q Sfei (a k Dole. ar City t-Cr-/f Zips2'/2— Phone# 331-1-3/8-8- <br /> <br />C-57 Contractor Mitchell Drilling Address 7900 Myrtle Ave City Eureka Zip95503 Lic# 672617 Phone# 707-444-9040 <br /> <br />Consultant/Sub Cntr Advanced GeoEnvironmental Address 837 Shaw Rd. CityStockton Licit 6 8 0 2 2 7 Phone# 209-467-1006 <br />GIS Coordinates: X V , Township Range Section <br />WORK TO BE PERFORMED: <br />Ff NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />13 SOIL BORING # <br />WELL # MW - 10 a PRESSURE GROUT <br />El *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />IT HOLLOW STEM DIA. OF BOREHOLE 8" a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 2" <br />AIR HAMMER/DRIVEN CASING THICKNESS SCD 40 TYPE OF CASING: U STEEL ff PVC 1:1 OTHER: <br />U MUD ROTARY DEPTH OF GROUT SEAL 60'TREMIE TYPE TO BE USED: Ef AUGERS U HOSE <br />U PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FA/ / DEPTH IS 30') <br />U HAND AUGER GROUT SPECIFICATIONS Portland Type II <br />I] OTHER APPROX. BORING DEPTH 8 5 ' EkBOLTED TRAFFIC BOX or a STOVE PIPE (......)-, <br />CONDUCTOR CASING PROPOSED NA (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />4U 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 Ordinances Rules n Regulations, and all applicable California State Laws. <br />Signed x <br /> <br />Title/Company Staff Scientist/Advanced GeoEnvironmental <br /> <br />Print Name Ally Colavita <br /> <br />Date 11 211 9 / 0 8 <br /> <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: Li At/ <br />WORK PLAN DATED: j o (f q To <br />TYPE OF WELL <br />fl MONITORING <br />1:1 EXTRACTION <br />El VAPOR <br />U AIR SPARGE/ OZONE <br />U SOIL BORING <br />U OTHER: <br />U OVER-BORE. DIAMETER <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: 1kJ421,( 6cov-I-tc, CrIAPC-k hit-r4A..411-t_ <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # 5 EC'D BY DATE # 1:%E134/44 E--RF-Q-----.............N\ NUEST I VOICE <br />4 5"C") <br />---c2 ,7 <br />ti Esetocv 2 6s3r Si <br />(t," 714 siktos 3 Li --L c) <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br /> <br />EHD 29-02-001 <br />6/22/04