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P4 'N oan Joaquin County , n <br /> JUL 12 20 <br /> 4 i} Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 952(ENVIRONMENT HE T IGATION <br /> (209) 468-3449 Fax : (209) 468-3433 Web: www.sjgov.org/ell'JRMIT/SERU{C <br /> UNIT <br /> FSR 'T Well Permit Application f ' loll <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 described. This application is made in compliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 3147 S . El Dorado Ivy Ave Stockton 95206 Assessors 175 - 120 - 03 <br /> WELL Location Cross Street City Zip Parcel# <br /> PROPERTY <br /> Owner Cal Tank Line Inc Address 3105 S . El Dorado St . City Stockton Zip 95206 Phone# 209 - 466 -3554 <br /> All Well Abandonment 6626 Merchandise Way Diamond Springs 95619 848359 1 - 530 -644 - 1609 <br /> C-57 Contractor Address cay Zip Lic# Phone# <br /> Consultant / Sub Cntr Advanced Geoenvironmentai Address 837 Shaw Rd City Stockton LIG# 680227 Phone# ( 209 ) 467-1005 - <br /> GIS Coordinates: X 379/ 862oo45y4 -11 /. 2T$LS l`I4$O , Township Range Section <br /> WORK TO BE PERFORMED: <br /> 8 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 8 DESTRUCTION (choose type below) <br /> 0 SOIL BORING # ® OVER-BORE. DIAMETER 8 - inch . <br /> a WELL # 0 PRESSURE GROUT <br /> 0 *Other GROUT SPECIFICATIONSPortland Type II Cement <br /> COMMENTS : see attached diagrams for well location and construction diagram <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 8 n MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL g PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL r 70 Ft:TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/ OZONE p PUSH POINT (GP or CPT) GROUT SEAL PUMPED: gcYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Type II Cement <br /> _7. <br /> [I OTHER:_0 OTHER APPROX. BORING DEPTH f35" l60 -Feet 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED no (if YES, list specifications in comment section) <br /> COMMENTS: <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS . M <br /> 48 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 v <br /> County O ances, Rules and Regulations, and all applicable California State Laws, O <br /> Signed x / l_. Title/Company ` <br /> Print Name a ,v �t (1t �l Cd� aA Ik xQ.d'O` Date C <br /> DEPARTMENT USE ONLY PSI NT <br /> R CEI -ED (� <br /> SITE MAP IN UNIT IV FILE, ADDRESS ] 3 1. 4 7_5`E I -Do ra Ut o eS } ree <br /> WORK PLAN DATED: N of <br /> , / SANJ O COUNTY <br /> Application Accepted By Y io�o ri a Me. CJI r +kl e v Date Issued �f 4, l0 � .1 �dhl <br /> Grout Inspection By AA __ Date l Inspection By Y We L°9if Date - E <br /> Destruction Inspection By i Gf0 Yl q IYLLLLjr g,L* Date 71.21 / 0 <br /> COMMENTS I CONDITIONS: De5 - ' r v G+i o n 0-0 PAVVf ^ S. r <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES 14 FEE INFO AMOUNT REMITTED CHECK # RECO BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> 3502 60 . 00 <br /> 3503 34svo 4os: oo 31440 �f 9 16 /o SR# 00 (� OSl B <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 />