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5 o C, San Joaquin County • <br /> Envionmental Health Department SITE <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 /> P <br /> Well Permit Application z <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r $ .. ', —L �' i' S9 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made)n conpli9-K'`e�wiFh�52rj' <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health DepartrYlta,.!. p r• a'"•I • I. <br /> ", �k7t;4;N T <br /> {' <br /> WELL Location 375 West Hazelton Avenue Cross Street Lincoln City Stockton Zip 95203 parcel#Assessors`►. %il?pZL <br /> PROPERTY <br /> Owner sierra Lumber manufacturers Address P. O. Box 6216 City Stockton Zip 95206 phone# (209) 943-7777 <br /> C-57 Contractor Advanced GeoEnvironmental Stockton <br /> Address 837 Shaw Road City Zlp 95215 Lic# 680227phone# (209) 467-1006 <br /> Consultant/Sub Cntr Advanced GeoEnvironmental Address 837 Shaw Road City Stockton Lic# Phone# (209) 467-1006 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> uNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br /> OSOILBORING# B-4, H-5 DOVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: NA <br /> 0 EXTRACTION [AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC [OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 50 feet TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE [{PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> IKSOIL BORING aHAND AUGER GROUT SPECIFICATIONS Portland cement <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 50 feet 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NA (if YES,list specifications in comment section) <br /> COMMENTS: work is deta_1ed in the AGE-prepared "Work Plan Addendum - November 2006" approved by EHD. <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 OrdinanW, Ijttlf s,and egulations, and all applicable California State Laws. <br /> Sinned x h/[','�d/ "//�'F Title/Company vice President <br /> Print Name Robert Marty Date 01-31-07 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By �11-K -� Date Issued ZL T Area <br /> Grout Inspection By OkL Date rI/J! Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: 77 `/ <br /> ACCOUNTING ONLY: AID# ` FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SR# <br /> C-57 WC=WAIVER___ C-57 Letter cf Authorization to sign permit_ Encroachment doc <br /> h tn)'9-u,-00 l <br /> 23:04 <br />