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r _ <br /> "•"� .cd San Joaquin County ,; <br /> Env �_-� mental Health De artinentr ��; <br /> p SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/chyJL I S) 1007 UNIT IV <br /> L1i"oti�'�P EiNViROWA111-:NT <br /> Well Permit Application �,,�-,v� HEAi=i=H . <br /> PER,IMIT/SER+!ICES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor 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 /> WELI-Location 355 Enterprise Place Cross Street Industrial wa Assessors <br /> v City Trac Zip 95304 � Parcel# 212-210-08 <br /> PROPERTY <br /> Owner . Address 2300 S RESERVIOR Cit POMONA 91766 209-830-7317 <br /> y Zip .Phone# <br /> C-57 Contractor Advanced GeoEnvironmental Address 837 Shaw Rd. City Stockton Zip95215 LIC# 680227 Phone#209-467-1006 <br /> Consultant 1 Sub Cntr Address City r Lic# Phone# <br /> 3 <br /> I <br /> ' S <br /> GIS Coordinates:X 'Y <br /> Township Range Section <br /> WORK TO BE PERFORMED: <br /> a NEW WELL 1 BORING (CPT, GEO PROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> USOILBORING# Bl-6, V1-4 DOVER-BORE, DIAMETER <br /> 0 WELL# <br /> 0*Other 0 PRESSURE GROUT , <br /> GROUT S A NS <br /> COMMENTS: <br /> ri in n sit <br /> !s ur x <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE i^25"0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: NA�_ <br /> 0 EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: U STEEL 0 PVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL-SFC-Tb TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE!OZONE ®PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes B No`(NOTE: MAXIMUM FREE-FA/1 DEPTH <br /> S 30 <br /> 13 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Cement Type I I ' <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH V=5' . 8=10-30' 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 /> 4UWORKING HOURS NOTICE REQUIRE=D 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 in and egulationsl and all applicable California State Laws. <br /> Signed x /i�'`'" Title/Company <br /> Print Name Robert Marty _Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 1r e <br /> WORK PLAN DATED' M 7 <br /> Application Accepted By )r r' h e1I Date Issued ]/. 3 'Z Area 1 4J�g <br /> Grout Inspection By L ` Date . <br /> —pz —6 7 Final Inspection,'By YYl r Date 0 0 <br /> Destruction Inspection By Date / <br /> COMMENTS 1 CONDITIONS: 07 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 5EC'D BY DATE: PERMIT/SERVICE REQUEST# INVOICE <br /> 35,01 69.0j <br /> 1� <br /> 35*o3 aSS, oa 7'q'. 1'?3-07 SR# l�05/ 3b�b f <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 />