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i <br /> �op..Qu•I . ,r t-�Ian Joaquin County <br /> Environmental Health Departmeft (� SITE <br /> Lam;_ � i;- _�i � <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 952 `+' =MITIGATION <br /> (209)468-3449 Fax: 209 468-3433 Web: www.s' ov.or <br /> { ) �� V60 C, -JC,E UNIT-IV <br /> �RClFOR � <br /> Well Permit Application ENVt'RC)Nl,.lE,,i 1-i AL7iI <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE I#ftm /.;F�l/{I}�q <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 /> Assessor?,,-3,,-,, <br /> WELL Location '1130 South Pilgrim street Cross Street Jackson St.City Stockton Zip CA Parcel# <br /> PROPERTY Mohammad Saeed <br /> Owner Islamic center of Stockton AddresS1130 South Pilgrim Stree6ity Stockton Zip 95205 phone# (209) 607-4956 <br /> C-57 Contractor"dvanced GeoEnvironmentalAddress 837 Shaw Rd. City Stockton Zip 95215uc#680227 Phone#209-467-1006 <br /> Consultant I Sub Cntr same as above Address City Lic# Phone# <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL!BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> ff SOIL BORING# 8-1 13-Z_ a OVER-BORE. DIAMETER <br /> 0 WELL# a PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: -Z nALP S /Rs4" -r � •� uS� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS G <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLEI 1/4 h MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL ll PVC o OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE —"Z> <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> I;SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Type I/II _. t'_k <br /> 0 OTHER: rkOTHER Geoprobe APPROX.BORING DEPTH 60' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications In comment section) n <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby ce that I have prepa his application and that the work will be done in accordance with San Joaquin <br /> County O i noes, Rules an egul tions, and all ap licable California State Laws. <br /> Signed i" l� L T' Title r pany Staff Geolo ist Advanced GeoEnvironmental Inc. <br /> Print Name Lauren Cardinalli _ Date o6/nrlos <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE ADDRESS: //303' Ayw <br /> WORK PLAN DATED: dper+ <br /> Application Accepted By l`C. 0 Date Issued 6/9 /Q Area /7 7 <br /> Grout Inspection By Date V6 Final inspection'By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: Z_el . <br /> ACCOUNTING ONLY: AID# FAC# <br /> FSE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> ra! q_ gF. a'17�� /-49-- C/'7/4* S R#OOS—qS-o/ <br /> C-57— WC=WAIVER_•_, C-57 Letter of Authorization to sign permit—Encroachment doc— <br /> EI-ID 29-02-001 ^ <br /> 6/ 2104 ' <br />