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U esan Joaquin County <br /> '° °� Environmental Health Department no SITE <br /> r W �rnU <br /> a < 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 <br /> jogfIION <br /> (209)468-3449 Fax: (209)468-3433 Web: WWW.sjgov.org/ehd U IV <br /> 4 ° 4` Well Permit Application MAY 1 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENpVIRONNIENT HEALTH with San <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appl��INII ®� I'Ol <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> sessors <br /> 135 East 1Y Ave Hunter CityStockton Zip - CA Parcel# 139-080-10 <br /> WELL Location PYlln Cross Street <br /> PROPERTY Address 316 N. E1 Dorado St. City Stockton Zip 95202 Phone# (209) 466-5311 <br /> Owner ST. JOHN'S EPISCOPAL CHURCH <br /> 837 Shaw Rd. kton 95215 0227 phone#209-467-1006 <br /> C-57 ContractorAdvanced GeoEnvironmental AddreSS OltyStocZip LIC#68 <br /> Consultant/Sub Cnlr <br /> same as above Address City Lic# Phone# <br /> GIS Coordinates:X <br /> y.,Township Range Section <br /> WORK TOB PEED: <br /> if NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') O OE ER UCTIRE. DN METER(choose type below) <br /> SOIL BORING# B-1, B-2, a-3, a-4, 8-5 O PRESSURE GROUT <br /> WELL# GROUT SPECIFICATIONS <br /> p*Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 4 <br /> p MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE= b MULTIPLECASINGSOF CAS <br /> ING:DMp TI- <br /> STEEL LEVEL Pvc LLO OTHERCASING DIA._ <br /> 0 EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> 0 AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 100I1-BORING aHAND AUGER GROUT SPECIFICATIONS I n T`roeBOLTED TRAFFIC BOX or D STOVE PIPE <br /> /IT <br /> 0 OTHER: OcOTHER Ge-probe APPROX.BORING DEPTH 40' D <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: B-1 through S-5 will be located around the Bite in the sidewalk as shown in PSA work tan. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I heLauren Car lnalli repared this application and that the work will be done in accordance with San Joaquin <br /> County ances, R as nd Regu tions,a all applicable California State Laws. <br /> Signe x Title/Company Staff Geologist/Advanced GeoEnvironmental,_ Inc. <br /> Date aV-L X08 <br /> Print Name <br /> DEPARTMENT USE ONLY 1 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3 S IF - t�v1n e S ttie�I <br /> WORK PLAN DATED: <br /> Application Accepted By 1/l1n w,.n r a�— <br /> Date Issued S�7 L�,2L Area <br /> Grout Inspection By IA1 ^CC.� <br /> Date L Final Inspection By L $�4gn,1 Date S� <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 1 SERVICE REQUEST# INVOICE <br /> 35-0Z�.oO ?--+- '3 5 76jof5 SR# JC Z6� <br /> So <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_,Encroachment doc x <br /> EHD 29.02-001 <br /> 6/22/04 <br />