Laserfiche WebLink
s <br /> 1... SAN JOAQUIN COUNTY � � ���V` <br /> ENVIRONMENTAL HEALTH DEPARTMENT NOV 2 6 2008 SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:whin Ii� �) EN f HEA(ftT IV <br /> �: <br /> WELL PERMIT APPLICATION <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 Tide,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor' <br /> Well Locatior,2417 West Lane crossstreet Klinger Road city Stockton zip 95205 Parcel# 117-09-008 <br /> Property <br /> Owner Joseph Rokoszewski Address2015 Harding Way city Stockton zip 95203 Phone# 916-729-1760 <br /> C-57 Contractor WRM Address BOX 8938 City citrus HeightssLic# 888763 Phone916-729-1760 <br /> Consultant/Sub Cntr WRM Address BOX 8938 City citrus Heights Lip# 888763 Phone916-729-1760 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL/BORING(CPT,GEOPR98E,HYDROPUNCH,HAND-AUGER,OTHER•) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ®SOIL BORING# 6 Borings ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑`OTHER GROUT SPECIFICATIONS <br /> COMMENTS: 6 Soil Borings to 60 Feet or groundwater and Collect ground water Samples <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE 4" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> Cl EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ®PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:E Yes C�p No (NOTE-::MAXIMUM FREE-FALL DEPTH IS 30') <br /> I$SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS A4n6/NA <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 60 Feet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (f YES,list swdiretions in mmmenl section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California�ifL s. <br /> Signed � `C /.:1 Title/Company 5,rnl ev 6tYi/u�•s)f'/�I/rlflM �lSOrf✓(C /IaNWjrMI •T- <br /> Print Name 6111 E• T3 a ll ay.l Date <br /> -7DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1 p _ <br /> WORK PLAN DATED: ..r/v� 30 1900-1 ,_ <br /> APPLICATION ACCEPTED BY i ' I DATE ISSUED [��AREA 1� <br /> GROUT INSPECTION BY FINAL INSPECTION BY __ �� TT DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO All REMITTED CHECK# RECV'D BY DATE PERMR/SERVICE# I INVOICE <br /> 35 $ 40 2q o'l _7)`V l 6 SR#.%0 JI <br /> C757 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EI-11329-01 1115M71WEB) WELL PERMIT APP <br />