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3an Joaquin County <br />Enyil onmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton CA, <br />I <br />t5,2f)2 <br />. -5 -- (209) 468-3449 Fax: (209) 468-717 3 Web: www.sigc144d E <br />Well Permit Application <br /> <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATEjs5pg p <br />LN <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work descFt," 0.1100113/4. made in compliance with San <br />vi <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Envircii fltiikbetj-nent.0-02 <br />153-090-01 <br />153-09 <br />Assessors 153903 153-090-04 <br />Parcel# 153-090-05 <br />153-090-06 <br />153-090-07 <br />PROPERTY <br />Owner BIER, WAYNE Address 1881 E.Market Street City Stockton Zip 95205 Phone# 209-939-1020 <br />C-57 Contractor Advanced GecEnvircnmencal Address 837 Shaw Rd. City Stockton Zip9522.5 Lio# 680227 Phone# 209-467-1006 <br />Consultant / Sub Cntr sams s a_bnve Address <br /> <br />City Lic# Phone# <br /> <br />GIS Coordinates: X Y Township <br /> <br />Range Section <br /> <br />WORK TO BE PERFORMED: <br />ja NEW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />a SOIL BORING # four borings <br />0 WELL # <br />*Other <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE. DIAMETER <br />O PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />COMMENTS: <br />WELL Location 1904-19 -36 Weber Ave. Cross StreetAbandoned "A" St City Stockton <br /> <br />Zip 95205 <br />TYPE OF WELL <br />O MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE/ OZONE <br />/3 SOIL BORING <br />0 OTHER: <br />COMMENTS: <br />INSTALLATION TYPE <br /> <br />CONSTRUCTION SPECIFICATIONS <br />9 HOLLOW STEM <br /> <br />DIA. OF BOREHOLE 1.25"MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: NA <br />0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: a STEEL 0 PVC 0 OTHER: <br />0 MUD ROTARY <br /> <br />DEPTH OF GROUT SEAL SFC-TD TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 9 Yes 9 No (NOTE: MAXIMUM FREE-FA/ / DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATIONS Portland Cement Type II <br />0 OTHER APPROX. BORING DEPTH 5-45 ' bscr 9 BOLTED TRAFFIC BOX or 9 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />4U WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />County Ordinan <br />Signed x <br />Print Name Robert Marty <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: oo — kct zu —1 ci 3 4 (A.! r <br />WORK PLAN DATED: t\ 5- (0 -3-• <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />I and egulationsi and all applicable California State Laws. <br />Title/Company Vice President <br />Date ing /07 <br />FILE COPY <br />Date Issued tt it3 4, <br />Grout Inspection By Ut:Nerk A.e's_ A r- Date It !I Lie (r1 Final Inspection By <br />Date <br />Application Accepted By C).-‘" <br />Destruction Inspection By <br />Area <br />Date t t I 7_53- 7— <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # 5EC'D BY DATE PERMIT I SERVICE REQUEST # INVOICE <br />SR# <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />EHD 29-02-001 <br />6/22/04