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San Joaquin County Iri]IR� LJ� ' <br />Environmental Health Department _ SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202, U <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd 2 �G�/ UNIT IV <br />Lr��ViI�ONr•1� - <br />Application p 4 i Ni NLZA T" <br />Well Permit A <br />PP ERf„iiT/SERVICES <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 />FEE INFO AMOUNT REMITTED <br />Joaquin County Development Title, Chapter 9-1116.3 and the Standards of San Joaquin County Environmental Health Department. <br />5 EC'D BY <br />Assessors <br />INVOICE <br />WELL Location Abancloned W b r Ave Cross StreetAbandoned "A" stcity Stockton Zip 95205 Parcel# 153-111-01 <br />'610 �� <br />IH Vv 6 <br />PROPERTY <br />Owner BIER, WAYNE Address 1514 E SCOTTS AVE. City Stockton Zip 95205 Phone# 209-939-1020 <br />C-57 Contractor Advanced Geo6nvironmental Address 837 Shaw Rd. City StoCkton Zip95215 LIC# 680227 Phone# 209-467-1006 <br />Consultant/ Sub Cntr shove Address City Lic# Phone# <br />GIS Coordinates: X 'Y Township Range Section <br />WORK TO BE PERFORMED: <br />g NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) D DESTRUCTION (choose type below) <br />R SOIL BORING # B-1 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT i <br />0 *Other GROUT SPECIFICATIONS LM <br />6 <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />D MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 1_25 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: NA VN <br />D EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL D PVC 0 OTHER: C <br />0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL SFC -TD TREMIE TYPE TO BE USED: D AUGERS D HOSE C <br />D AIR SPARGE/ OZONE H PUSH POINT (GP or CPT)GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE -FA/ / DEPTH IS 30') <br />a SOIL BORING D HAND AUGER GROUT SPECIFICATIONS Portland Cement Tyne II <br />D OTHER: D OTHER APPROX. BORING DEPTH 40' bsg D BOLTED TRAFFIC BOX or D STOVE PIPE <br />CONDUCTOR CASING PROPOSED (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 Ordinan "and egulationsI and all applicable California State Laws. <br />Signed x pq A.; Title/Company Vice President <br />Print Name Robert Marty Dated/9.n/o7 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS:-�i✓�..u0 <br />WORK PLAN DATED: 6 Z`i o i - <br />Application Accepted ByDate Issued * f L 140 4- Area <br />Grout Inspection By �j, ten. _' Date 7(a (TFinal Inspection By Date--T42.6�� <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />5 EC'D BY <br />DATE P MIT / SERVIC QUEST # <br />INVOICE <br />Ao <br />'610 �� <br />S`i/� <br />SR#off Sly <br />C-57—/ WC= WAIVER_ C-57 Letter of Authorization to sign permit? n7 t ��oc_ <br />EHD 29-02-001 <br />6/22/04 <br />