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o U►H -An Joaquin County <br /> z� oz EnvirdrInental Health Department �' PAYMENT SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 �ECE(VEpiffiTIGATION <br /> • (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd FEB 10 29WUNIT IV <br /> A a�P JOAQUIN COUNTY <br /> IPO Well Permit Application <br /> tS�ENVIRONM <br /> t.{EAj_TH DEPARTMENT <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 /> PROPERTY MASON ITE DOOR CORP <br /> Owner c/o Tom Crawshaw Address 1 N DALE MABRY HWY #95o City TAMPA FL Zip 33609 Phone# (630) 513-4444 <br /> C-57 Contractor Advanced GeoEnvironmental Address 837 Shaw Road City Stockton Zip95215 Llc#680227 Phone# 209-467-1006 <br /> Consultant/Sub Cntr Adv. GeoEnvironmental Address 837 Shaw Rd. Citystockton LiC# 680227 Phone# 209-467-loo6 <br /> GIS Coordinates:X 'y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 8 NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> II SOIL BORING# B-7, B-8 a OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: Please refer to Work Plan, dated 01/12/2010 ___ <br /> vi <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING a HOLLOW STEM DIA.OF BOREHOLE-2" Q MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: na <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS na TYPE OF CASING: a STEEL o PVC a OTHER: na <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 5' TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> p AIR SPARGE/OZONE ff PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes ff No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> If SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Type II Portland <br /> a OTHER:_0 OTHER APPROX.BORING DEPTH 5' a BOLTED TRAFFIC BOX or a STOVE PIPE G <br /> CONDUCTOR CASING PROPOSED na (if YES,list specifications in comment section) r <br /> COMMENTS: Please refer to EHD-Approval letter, dated 02/03/2010 <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, 5u1Mand itegulations, and all applicable California State Laws. <br /> Signed x i'W Title/Company Vice President <br /> Print Name_._Robert Marty Date 02/10/10 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3 3 <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issue t L L Area k <br /> Grout Inspection By Date Final Inspection <br /> By <br /> Grout S 4 <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 /> X34- 30-4411 SR#Sg3sra <br /> C-57v,�' W _-WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />