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San Joaquin County E2 <br />L'llr \ Environmental Health Department TIDSITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />'JUN 29 MITIGATION <br /> <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.orz/ehd 42( <br />cis.A/PRI)A11.1-Ar <br /> <br />PER <br />17SERVICES <br /> UNIT IV <br />Well Permit Application - hEALri <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 />Assessors WELL Location Abandoned Weber Ave. Cross Street Abandoned "A. St City Stockton Zip 95205 <br />PROPERTY <br />Owner BIER, WAYNE Address 1514 E SCOTTS AVE. City Stockton Zip 95205 Phone# 209-939-1020 <br /> <br />C-57 Contractor Advanced GeoEnvironmental Address 837 Shaw Rd. City Stockton Zip 95215 Lia 680227 Phone# 209-467-1006 <br /> <br />Consultant / Sub Cntr same as above Address City <br /> <br />Lic# Phone# <br /> <br />GIS Coordinates: X <br /> <br />, Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />11 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />s SOIL BORING # B-1 a WELL # <br />a *Other <br />COMMENTS: <br />DESTRUCTION (choose type below) <br />0 OVER-BORE. DIAMETER <br />0 PRESSURE GROUT GROUT SPECIFICATIONS — <br /> <br />19 vo 6 lock Wk-13F-(2._ <br />Parcel# 153-111-01 <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE ['MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: NA <br />CASING THICKNESS NA TYPE OF CASING: ['STEEL 0 PVC U OTHER: <br />DEPTH OF GROUT SEAL SFC-TD TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />AIR SPARGE/ OZONE fl PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes U No (NOTE: MAXIMUM FREE-FA/ / DEPTH IS 30') <br />11 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Cement Type II <br />U OTHER: a OTHER APPROX. BORING DEPTH 40 'beg a BOLTED TRAFFIC BOX or El 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 Joarlfil <br />County Ordinan I and egulationsi and all applicable California State Laws. ramp <br />rri <br />Print Name Robert Marty Date 06/20/07 <br /> <br />DEPARTMENT USE ONLY C. 0 <br />SITE MAP IN UNIT IV FILE, ADDRESS: .46,-.,‘"etfiA.L.e1 'A'' c -i-- • <br />WORK PLAN DATED: t, 1 ).--`1 (0 i- ea< <br />Application Accepted By UttAA"..e's---1e-\, Date Issued i 1 I 1-tio - Area <br />Grout Inspection By t, \,AAAA.r--- r" Date 719,6 (0- Final Inspection By lite,,AAce.,„,..._ Date <br />Destruction Inspection Inspection By Date <br />COMMENTS / CONDITIONS: <br />TYPE <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />MONITORING a HOLLOW STEM <br /> <br />0 EXTRACTION U AIR HAMMER/DRIVEN <br />VAPOR 0 MUD ROTARY <br />Signed x Title/Company Vice President <br /> <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # 5 EC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />9n° 1 a s-(1).--7 V A 6°I o' -1-1,-,10/- sR# 5 0 <br />C-57 Letter of Authorization to sign permit Encroachment doc C-57 WC -WAIVER <br />EHD 29-02-001 <br />6/22/04