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San Joaquin County <br />7-7 Environmental Health Department Lfr-11 F-7 SITE „ 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIG AT ION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd(p i. s 2005 UNIT IV <br />Well Permit Application L.IV,IfiUNME:NT HEALTH <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 <br />Owner MASONITE DOOR CORP Address 1 N DALE MABRY HWY #950 City TAMPA FL Zip 33609 Phone# (630) 513 -4444 <br />C-57 Contractor All Well Abandonment Address 3809 Pleasant Valley Rd. City PlacervilleZip 95667 Lic# 548359 Phone# 530-644-1122 <br /> <br />Consultant/Sub CntczidVanced GeoEnvi ronmental Address 837 Shaw Rd, City Stockton Lic# 680227 Phone# 209-467-1006 <br /> <br />GIS Coordinates: X , Y Township Range Section <br />WORK TO BE PERFORMED: <br />if NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />SOIL BORING # U OVER-BORE. DIAMETER <br />g WELL # MW-S. Nivq-7 <br />*Other <br />PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />COMMENTS: <br />Li <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (-• <br />ti MONITORING THOLLOW STEM DIA. OF BOREHOLE 8 " a MULTIPLE CASINGS g MULTI-LEVEL WELL CASING DIA: 2 " _ <br />) U EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCHD 40 TYPE OF CASING: a STEEL g PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 8 ' TREMIE TYPE TO BE USED: 5 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE g PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FA/ / DEPTH IS 30') <br />0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Type II Portland <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 30' B BOLTED TRAFFIC BOX or a 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 Ordinan rjd egulationsi and all applicable California State Laws. <br />Signed x Title/Company Vice President <br />Print Name Roberr. Marty Date 08/18/08 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: Li c_o I Vs <br />1 CB I Date Issued 3 Area 61_ y -)- <br />Date <br />' <br />1 ct /al Final Inspection By M. ,Lffiler ,o Date $111163 <br />Date <br />COMMENTS / CONDITIONS• <br />ACCOUNTING ONLY: AID# FAC# '3--"-/ (1)6.-i/e '3 <br />'RMLI <br />5/11:123) <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # go BY tilu DATE / SE CERVI REQUEST # I E <br />350 \ <br />350--5 <br />15 <br />_clui 3<g3 .1.-)os--__ --1,-y\_ 5\v53 ,--8 sR# <br />WORK PLAN DATED: 1.--11 -) 6 -7 <br /> Application Accepted By <br />Grout Inspection By `----7Y\ • <br />Destruction Inspection By <br />C-57 WC <br /> <br />-WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />EHD 29-02-001 <br />6/22/04