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*San Joaquin County 0 <br /> .Xijw><ronmental Health Department SITE <br /> ++ ` rm Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> *1F0 !,k\A <br /> 09)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> q 2o�1 Well Permit Application <br /> NBLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Dev pier 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> City of Stockton ght of way 135 East Miner Ave Assessors <br /> WELL Location Cross Street Hunter city Stockton Zip 95202 Parcel# <br /> PROPERTY 3425 N E1 Dorado St. Stockton 95202 <br /> Owner city of Stockton Address City Zip Phone# (209) 937-8500 <br /> C-57 Contractor Advanced GeoEnvironmentalAddress 837 Shaw Rd. City Stockton Zip 95215 Li0080227Phone#209-467-1006 <br /> Consultant/Sub Cntr Address CityLic# Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 13 NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 'b SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE2.25" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 65 1 TREMIE TYPE TO BE USED: 30 AUGERS 0 HOSE <br /> 0 AIR SPARGE1 OZONE )a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> x0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Pnrtland Typp T/TT <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 65' BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: e 'll be loc.t.d in the sidewalks/roadwayn k 1 <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 Orddi/na ,c s, Rules andel Regulations, and all applicable California State Laws. <br /> Signed x t/" 1 � A&4—j Title/Company Geolog' st/Advanc d GeoEn �ronmental Inc <br /> Print Name William Little Date ol- n6 -2ol?— <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: l �i fyhn- in /a <br /> WORK PLAN DATED: � I Z4� !! <br /> Application Accepted BDate Issued l I I 1� I '2. Area <br /> Grout Inspection By Date Final Inspection B�'—T Date <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 /> 3505' Izb.00 3y12`j p IItfi SR# 6tAl <br /> C-57j,�- WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc x <br /> EHD 29-02-001 <br /> 6/22/04.1 $j 3 7.06 3'{310 <br /> -2 Sa3 <br />