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San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />n1D ECRE�.gSITE <br />U1j L`1 ►� ION <br />UNIT IV <br />MAY 168 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT r HEALTH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This apRE&Jf0'f { /@Ff"GapTpliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location 135 East Oh-er AveAssessors <br />Cross Street Hunter 139-080-10 <br />City Stockton Zip CA Parcel# <br />PROPERTY 316 NE1 Dorado StStockton 95202 <br />Owner N. . ST. JOHN'S EPISCOPAL CHURCH Address City Zip Phone# (209) 466-5311 <br />C-57 Contractor Advanced GeoEnvironmental Address 837 Shaw Rd. City Stockton Zip 95215Lic#680227 Phone# 2 0 9 - 4 6 7 - 10 0 6 <br />Consultant / Sub Cntr same as above Address City Lic# Phone#. <br />GIS Coordinates: <br />WORK TO BE PERFORMED: <br />ly NEW WELL / BORING <br />SOIL BORING # B-1 <br />WELL # <br />0 *Other <br />COMMENTS: <br />Y <br />Townshi <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />B-2, B-3, 2-4, B-5 <br />Range Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE' 1/4 b MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />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 TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <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 />)($OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Type I /I I <br />0 OTHER: DcOTHER Geoprobe APPROX. BORING DEPTH 40' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: 13-1 through B-5 will be located around the site in the sidewalk as shown in PSA workplan. <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that I <br />County "d�tances, <br />Sig <br />Print <br />SITE MAP IN UNIT IV FILE, AD <br />WORK PLAN DATED: N <br />this application and that the work will be done in accordance with San Joaquin <br />Iltionsr-aad\applicable California State Laws. <br />Title/Company Staff Geologist/Advanced GeoEnvironmental, Inc. <br />DEPARTMENT USE ONLY <br />SS: 13 E tyl vvA-�, <br />Date os/131oa <br />Y ' <br />Application Accepted By CA� Date Issued d Area <br />Grout Inspection By CCA/-- Date Z Final Inspection By��C2 Date S. <br />Destruction Inspection By Date <br />COMMENTS/CON <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />EQUEST # <br />INVOICE <br />35-011 <br />So 3 <br />goo <br />If -110 <br />Z- �-�`j 3 <br />!tii <br />►6/vF5 <br />S R# <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 />