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San Joaquin County <br />Environmental Health Department ORiGIN M <br />ITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />Well Permit Application 2ru`a DEC 18 Pi'i 2* 03 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DA <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the woi <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County <br />ISSUED <br />:1 <br />c () L) T <br />.1'� ; � v <br />{b�cJ`.i4 <br />p3bcp"Rt4-Made in compliance with San <br />WithiLLLityo Stockton Pr�erty_(see comments) J� J Assessors <br />WELL Location ;:.-Cross Street City faCK r Y\Zip 13c -e Parcel# <br />PROPERTY CITY OF STOCKTON (See attached encroachment permit) <br />Owner Address City Zip Phone#. <br />Advanced GeoEnvironmental 837 <br />C-57 Contractor Address <br />Advanced GeoEnvironmental <br />Consultant / Sub Cntr Address <br />GIS Coordinates: <br />I'd <br />Shaw Road <br />837 Shaw Road <br />Township <br />City Stockton Zip 95215 Lic# 680227Phone# 467-1006 <br />City Stockton Li C# 680221 Phone# 467-1006 <br />Section <br />WORK TO BE PERFORMED: <br />xb NEW WELL / BORING_ 4(CPB_ s EOBP ROBE, H7YDRBOPBUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />,4SOIL BORING # 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: Adjacent to 2057 So El Dorado/2070 So El Dorado/ 9 Delhi Street (see City Encroachment Permit) <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 1.25"0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:----- <br />a <br />IA:_____0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TD TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE TPUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />)qSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Type II portland <br />0 OTHER:_G OTHER APPROX. BORING DEPTH First GW (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 />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that I have ndg <br />his application and that the work will be done in accordance with San Joaquin <br />County Ordin es, slations, and all applicable California State Laws. <br />Signed x Title/Company PM/ADVANCED GEOENVIRONMENTAL, INC,, , /A nr-n�I <br />Print Name ARTHUR DEICKE L/ Date 18 DECEMBER 2006 RECEIVED <br />DEPARTMENT USE ONLY <br />DE': 1 5 2006 <br />`lJ <br />O <br />S <br />-i, <br />11 <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: SAN JOAQUIN COUNTY <br />I, ( H TH PARTMENT <br />Application Accepted By Alm r Date Issued "ii -L bb Area <br />Grout Inspection By Date L '51 101, Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />a 3 <br />3 0\ <br />v'o <br />o� <br />'&37q. C D <br />'f � <br />�./�/ <br />l- Il61C� <br />SR# bc���2.s <br />C-57_ WC VkAIVER-t* C-57 Letter of Authorization to sign permit�AU Encroachment doc ✓ <br />EHD 29-02-001 <br />6/22/04 <br />