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Pgy�N San Joaquin County <br /> °G Environmental Health Department '` r--fi, = I'`!i -" SITE <br /> N• � 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> MI tGATION <br /> •' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehdt�;=,'' 1 ,nf;8 UNIT IV <br /> cRt«aR�''P Well Permit Application T <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 /> Assessors <br /> WELL Location 433 W SCOTTS AVE STOCKTON Cross Street Lincoln St. City Stockton Zip 95203 Parcel# 147-040-44 <br /> PROPERTY630) 513-4444 <br /> Owner MASONITE DOOR CORP Address 1 N DALE MABRY ewY 4950 City TAMPA FL Zip 33609 Phone# ( <br /> C-57 Contractor All Well Abandonment Address 38o9 Pleasant Valley Rd. City PlacervilleZlp 95667 Lic 848359 phone#530-644-1122 <br /> Consultant/Sub CntrAd.,-need GeoPnyi,=enta� Address 837 Shaw Rd. Citystockton Lic#680227 Phone# 209-467-1006 <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> O NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> ff WELL# mw-r. Mw-7 0 PRESSURE GROUT <br /> p*Other GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> :0 MONITORING a[HOLLOW STEM DIA.OF BOREHOLE_U_° a MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCHD 40 TYPE OF CASING: 0 STEEL B PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 8' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FA// DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Type II Portland <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 30' $BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED na (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 that the work will be done in accordance with San Joaquin <br /> County Ordinanrjuld egulationsI and all applicable California State Laws. <br /> Signed x "/Jz 11 Title/Company Vice President <br /> Print Name Robert Marty Date 08/18/08 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 9 33 <br /> WORK PLAN DATED.: 1 :1- <br /> Application Accepted By Y \ - Date Issued 0 Area <br /> Grout Inspection By Date 01Final Inspection By Date O <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# UC'D BY DATE PFRMi7 <: ICE REQUEST# INVOICE <br /> 3so3 y � 343 �� o��-- ��- 3 1•� �� ���Y- ��,�,3� <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encl )acn,--hent doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />