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*San Joaquin County 011 <br /> Environmental Health Department 5))r- SITE <br /> p I t?I/� r i 'IVIITICATION <br /> ra 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 <br /> • (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> 4f( UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PFR tl ,�, <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This applicatlofiiriia6@,iFj 2ompliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. - 153-040-15 <br /> Assessors 153-090-14 <br /> WELL Location 1 S73 1531 2555 E MAIN sT Cross Street s. wilson way City Stockton Zip 95205 parcel# <br /> 153-040-11 <br /> PROPERTY <br /> Owner BIER. WAYNE Address 1514 E SCOTTS AVE. City Stockton Zip 95205 Phone#209-939-1020 <br /> C-57 Contractor Aavanoea ceoenvlronmencal Address 837 Shaw Rd. City Stockton Zip95215 Lick 680227 Phone# >n4-447-1 no4 <br /> Consultant/Sub Cntr as aboc Address CityLic# 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') O DESTRUCTION (choose type below) <br /> g SOILBORING# B-5,B-6,2-7 aOVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT "J <br /> 1]*Other GROUT SPECIFICATIONS <br /> COMMENTS: - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE 1_25^a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: NA <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> u VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Fa G TD _TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FA// DEPTH IS 30') <br /> ;j SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Cement Type Il <br /> 0 <br /> OTHER:_a OTHER APPROX.BORING DEPTH B5,7=10'/B6=40- 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. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinan"lam and egulationsI and all applicable California State Laws. <br /> Signed x '//L'� Title/Company vice President <br /> Print Name Robert Marty _Date -02-40, <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I - 1 5_S_t W/"r <br /> WORK PLAN DATED: b ai IO 7 <br /> Application Accepted By 1 AN! ✓ rn Date Issued <br /> ref f>�10 7— Area <br /> Grout Inspection By 41� Date �'Ir'A �0-7— Final Inspection By (�f„ <<wi Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 5EC'D BYDATE PERMIT/SERVICE REQUEST# INVOICE <br /> a t2 I `til , J(� 7 ', c✓ � x-11 D SR# 75 1 Oli <br /> C-572 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6122/04 <br />