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*San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 J&/,V ��I WITIGATION <br /> • (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.��e�jd ,9 UNIT IV <br /> F Well Permit Application P�9f1����%NT «0 <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 applications made in compliance with San <br /> Joaquin County Development Title,Chapter 5-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location 1881 E MARKET ST Cross StreetA andoned „A„ st City Stockton Zip 95205 Parcel# 153-040-03 <br /> PROPERTY <br /> Owner BIER, WAYNE Address 1514 E SCOTTS AVE. CityStockton Zip 95205 Phone#209-939-1020 <br /> C-67 Contractor Advanced GeoEnvironmental Address 837 Shaw Rd. CityStockton Zip95215 Li0# 680227 Phone# 209-467-1006 <br /> Consultant/Sub Cnlr flame a oho Address CityLid# Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> g NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> Ig SOILBORING# 13-2,B-3,B-4 DOVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS nlL4-rdg4"w,- <br /> COMMENTS: — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE1_25°0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: NA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL SFC-TD TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE d PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FA// DEPTH IS 301) <br /> B SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Cement Type II <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH a2=40';a3,4=20� 0 BOLTED TRAFFIC BOX or p 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 Ithat the work will be done in accordance with San J quin <br /> County OrdinanYjlpr,and egulationsl and all applicable California State Laws. <br /> Signed x � /sC'+'� Title/Company V'ce President 9"M <br /> Print Name Robert Marty _ Date <br /> DEPARTMENT USE ONLY ng/2n/o7 CO20 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I $ tc l t1A on L,A S SWO <br /> WORK PLAN DATED: <br /> Application Accepted By IA, � Acr"-h Date Issued - l'Z-IO�_Area <br /> Grout Inspection By_I��• Ate Date ti o Final Inspection By LA=6Am Dale � O <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PECODES FEE INFO AMOUNT REMITTED CHECK# 6EC'DBY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 2ao( 5tcs9,vo a-s`js7 I,t( 12 � <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 />