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San Joa uin County <br /> ,np4 ' "' �G q N I �� <br /> Environmental Health Department SITE <br /> .44600 East Main Street, Stockton, CA 95202-3029 MAR �, "� '00MITIGATION <br /> ww.sjgov.or ehd <br /> (209) 468-3449 Fax: (209) 468-3433 Web : w <br /> � ! 7P;;L-rUNIT IV <br /> AG / F OHS {f '^ <br /> Well Permit Application I ;1Q;1,'SEI',Vr <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 /> CITY OF STOCK ON ROW <br /> WELLLocatlon 2050 EAST FREMONT ST LAUREL ST STOCKTON 95205 Assessors <br /> Crass Street City Zip Parcel# <br /> PROPERTY 22 East Weber Ave Stockton 95202 <br /> Owner City of Stockton Address City Zip Phone# ( 209 ) 937 - 8411 <br /> Advanced GeoEnvironmental <br /> C-57 Contractor Address 837 Shaw Road City Stockton Zip 95215 UC#680227 Phone# 209 -467 - 1006 <br /> Advanced GeoEnvironmental <br /> Consultant / Sub Cntr Address 837 Shaw Road City Stockton Lic# 680227 phone# 209 - 467 - 1006 <br /> GIS Coordinates: X., Y., Township Range Section <br /> WORK TO BE PERFORMED: - <br /> )VNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") 0 DESTRUCTION (choose type below) <br /> USOIL BORING # 2 -10 a OVER-BORE. DIAMETER <br /> a WELL # o PRESSURE GROUT <br /> a "Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA. OF BOREHOLE1_5 F 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: .-- <br /> a <br /> IA: _-_a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 65 feet TREMIE TYPE TO BE USED: jj:AUGERS a HOSE <br /> a AIR SPARGE/ OZONE !PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yes ziNo (NOTE : MAXIMUM FREE-FALL DEPTH IS 30') <br /> X8 SOIL BORING aHAND AUGER GROUT SPECIFICATIONS TYPE II / PORTLAND CEMENT <br /> a OTHER: p OTHER APPROX. BORING DEPTH 65 FEET p BOLTED TRAFFIC BOX or a 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 prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules-and Regulations, and all applicable California State Laws. �+ <br /> y <br /> Signed / Title/Company VP/Advanced GeoEnvironmental , In <br /> 7 _ ri <br /> Print Name <br /> �ROHERT` E . MARTY Date � — t <br /> DEPARTMENT USE ONLY V <br /> SITE MAP IN UNIT IV FILE, ADDRESS : Z 0 5 C, � vA^ -i� 544 41 <br /> WORK PLAN DATED : _Js <br /> Application Accepted By ( 1 � o. s,. Date Issued Y / I 18 A <br /> Grout Inspection By Date I _Final Inspection By 4� ,A n� Date_ t <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 345a I 8-q . 00 <br /> 5-03 � ( z �( Y-o o z 3�3 I&OF IS 5L 53441 <br /> C-57 WC=WAIVER_ C-57 Letter of Authoriant !on to sign permit_ Encroachment doc ✓ <br /> EBD 29-02-001 WEB <br /> 9/11 /2007 <br />