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qu."�-..to .an Jkoaquin County <br /> 2 `v EnviivnmentalHea16;r Department • SITE <br /> ` 304 East WeberAvenuc, 3rd F'c,)r, Stockton, CA 9520`8`51 -MITIGATION <br /> c P ' (209)468-3449 Fax: (?"1 68-3a V m ,,�w.sjgov.org" UNIT IV <br /> c,FOR� Well FIctri,lb P,,., ;'_r.1liun <br /> �r <br /> NON-REFUNDABLE PERN.IT EXPIRES 1 Y-AR FROM DATE ISSU <br /> At <br /> 1'A�-(1tq ' ., rd <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describe : 6fati - is A64 in compliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environment t� ituat 0 <br /> Assessors <br /> WELL Location i AAS P MARKFT qTRFFT Cross StreetAba.aor<ed „A„ se City Stockton Zip 95205 Parcel# 153-040-03 <br /> PROPERTY <br /> Owner BIER, WAYNE Address 1881 E.Market Street City Stockton Zip 95205 Phone# 209-939-1020 <br /> C-57 Contractor Advanced ceoenviznnmencal Address 837 Shaw Rd. City Stockton Zip95215 Lic# 680227 phone# 209-467-1006 <br /> Consultant/Sub Cntr ..MA as Ahnva Address City Lic# 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 /> IJ SOIL BORING# 16 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,a MULTIPLE CASINGS a 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 /> p VAPOR p MUD ROTARY DEPTH OF GROUT SEAL SFc-TD TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 6 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FA/ / DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Cement Tvoe II <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 5-45- bsa 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{y_e,,s,y fj�uld egulationsl and all applicable California State Laws. <br /> Signed x //'fTitle/Company Vice President <br /> Print Name Robert Marty Data <br /> DEPARTMENT USE ONLY I ILL UP I <br /> SITE MAP IN UNIT IV FILE, ADDRESS: (�5£6) e, yv\rn^M�L,4— S 4 - <br /> WORK PLAN DATED: 15-(f) :�t <br /> Application Accepted By Date Issued It 1 ,31c,-; Area 6 2(q <br /> Grout Inspection By Ll�nv.rr — Date I i Irk Final Inspection By I, (sot 09- Date Lj!�d. <br /> Destruction Inspection Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 5 EC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> zetc)1, { gq.ov z 6sz�t ( � (ta(o� SR# <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 />