Laserfiche WebLink
Ui - � FILE COPY <br /> �o q ^�•..�a San Joaquin Count <br /> Environmental Health Dep rtmen PAYMENTSITE <br /> �. s CA 9520-3029 MITIGATION MIT GATION <br /> 600 East Main Street, Stockton, $ <br /> (209)468-3449 Fax.(209)468-3433 Web: w1vw.sjgov.oV9d- UNIT IV <br /> SW JOAQUIN COUNTY <br /> Well Permit Application ENVI�N� �N�J q <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FR M DATE 1SSU�D f l'(� 6 <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 Cc unty Environmental Health Department. <br /> Charter Way Assessors <br /> WELL Location 1033 West Charter Way Cross Street Navy ity Stockton Zip 95206 Parcel# 163-23G-41 <br /> PROPERTY NCC Properties PTP PO Box 1107 Stockton CA 209-465-5883 <br /> Owner Address City M Zip Phone# <br /> AGE 837 Shaw Rd. Stockton CA 680227 209-467-1006 <br /> C-57 Contractor Address Cit Zip Lic# Phone# <br /> Consultant/Sub Cntr AGE Address 837 Shaw Rd. City Lic#Stockton 680227 209-467-1006 <br /> p / Phone# <br /> GIS Coordinates:X 3 L�1O Y —12-1- 3'02-- ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> b NEW WELL/BORING (CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> $SOILBORING# V-1 & V-2 _ 0 OVER-BORE. DIAMETER d <br /> B WELL# 11 PRESSURE GROUT <br /> 0*01her GROUT SPECIFICATIONS �1 <br /> COMMENTS: See EHD--approved work plan, dated 04/06/2009 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIO14S <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE 211 (]MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: na <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: U STEEL ©PVC BOTHER: <br /> o VAPOR Ia MUD ROTARY DEPTH OF GROUT SEAL 5' TREMIE TYPE TO BE USED: a AUGERS o HOSE <br /> B AIR SPARGE/OZONE ITPUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes MNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> [`SOIL BORING o HAND AUGER GROUT SPECIFICATIONS PORTLAND TYPE 11 <br /> B OTHER: fi OTHER APPROX.BORING DEPT" 51 o BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (if YES,list specifications in comment section) <br /> COMMENTS: See EHD-approval letter dated 05/04/2009 Jr <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 wor i will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable Califo nia State Laws, <br /> i <br /> Signed x 7 Title/Company PROJECT GEOLOGIST/A.G.E_ <br /> Print Name TIMOTHY J. CUELLAR Date 0 ZO 9 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: !O <br /> WORK PLAN DATED: - .d5? <br /> Application Accepted By Date Issued S'�� Area <br /> Grout Inspection By Date Final Insp action By Date <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY I ATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> °' sora SB `C % VDef: C D acT SR# 45331 <br /> C-57 ✓ WC✓-WAIVER___- C-57 fetter of Authorization to sign permit* <br /> ermit Encroachment doc N I <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br /> FILE <br /> Copy <br />