Laserfiche WebLink
San Joaquin County �c�[i �����/�IL <br /> s r: Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MAr, 2007MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.ork9*NhtLN-j FIEAL1T'UNIT IV <br /> Well Permit Application PERI ITSERVIC <br /> ,� .. <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 /> Woodbridge Road Woodbridge, CA 95258 Assessors 01521060 <br /> WELL Location 19720 North Benedict Drive Cross Street City g Zip Parcel# <br /> PROPERTY 0900 <br /> Owner Woodbridge Sanitary Distri��dress19720 North Benedict Drive City Woodbridge Zip phone# (209)368- <br /> anF�cho 916 <br /> C-57 Contractor Cascade Drilling Address 3632 Omec Circle City C'orrlova Zip95742 Lic4717510 Phone#( )6 38 1169 <br /> Consultant/Sub Cntr <br /> ECO:LOGIC Engineering Address 777 N. Pershing Ave 2B City Stockton Lic# Phone#(209)242-0292 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/ BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> o SOIL BORING# a OVER-BORE. DIAMETER <br /> o WELL# 0 PRESSURE GROUT <br /> Other Hydropunch GROUT SPECIFICATIONS <br /> COMMENTS: Up to six(6)sites <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br /> VAPOR MUD ROTARY DEPTH OF GROUT SEAL 3D t TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> g AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER: OTHER APPROX. BORING DEPTH BOLTED TRAFFIC BOX or a 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 /> 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 Ordina ions, and all applicable California State Laws. <br /> ECO:LOGIC Engineering <br /> Signed x Title/Company ? -2 <br /> Print Name /" �/ ���� I Date J � <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ! P E3srL i� ► u��`"� �`�P� <br /> WORK PLAN DATED: / / <br /> Application Accepted By Date Issued L/l�[� � Area <br /> Grout Inspection By / '� Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: (� �✓ ( { <br /> ACCOUNTING ONLY: AID# FA # <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 01 �1� 9`1 �c�3Z iJ � y e � SR (��S Up �,; 1� <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />