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�oPa •! r..�o 0an Joaquin County . <br /> Envh vnmental Health Department SITE <br /> u' 304 East Weber A,rruc, 3rd Floor Stockton, CA 9 02 MITIGATION <br /> (209)468-3449 Fax: '' )y -ii S-34 3 Web: www.sjgov ,71�ii U��C U UNIT IV <br /> c �P <br /> q<,FOR� Well P=-,-1Tr.. Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work desaa •rWItey�p��� <br /> lldati Ui• rhede in compliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County EnvironrrRF 0Vq X_3.W@&t. 153-040-09 <br /> 153-090-11 <br /> Assessors ls1-aao-lz <br /> WELL Location 1 i ;1 1 55 ATN sT Cross Street s4 wilson way City Stockton Zip 95205 Parcel# <br /> PROPERTY <br /> Owner BIER. WAYNE Address 1881 E.Market Street City Stockton Zip 95205 Phone# 209-939-1020 <br /> C-57 Contractor Aalan�ea GeoEnvizonmen[al Address 837 Shaw Rd. City Stockton Zip95215 Lic# 680227 Phone# 2ng_dav_r nna <br /> Consultant/Sub Cntr nhnyP Address City Lio# Phone# <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> g NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> g SOIL BORING# seven borings 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 1,25"g MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: NA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL SFC!-II) TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 5 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FA/I DEPTH IS 301) <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Cement Type II <br /> 0 <br /> OTHER:_0 OTHER APPROX.BORING DEPTH 5-451 bsg 0 BOLTED TRAFFIC BOX or 0 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 /> 4U WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. RECEFFU <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqqu!n <br /> County Ordinan d and egulationsl and all applicable California State Laws. NOV Q 9 M7 <br /> c <br /> Signed fL`i/ Title/CompanyVine President Ct\I\/IRRA.IdhCNT LIFbITN <br /> Print Name Robert Marty Date r 1/nq/o7 PERMIT/SERVICES <br /> DEPARTMENT USE ONLY n V <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 15 3- 1 S 3 I-! S5 L' - Wl a r S^{• r 1 I F 1 n_O 1' i <br /> WORK PLAN DATED: 111> <br /> Application Accepted 8 1,Lle Date Issued II 1 1310 --)— Area 4Z 19 <br /> Grout Inspection By I' �.'Aanr»l Date Il S' Final Inspection By t1 bo off• Date IAS^^ <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# SEC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> z�ol �{ &9.vo 2bsz�l (y� u'r3foi SR# 5Z5� <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 />