Laserfiche WebLink
IF <br /> .4. <br /> #061�107 <br /> San Joaquin County <br /> En ironmental Health Department SITE <br /> 304 Eas Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> (209)468- 49 Fax: (209)468-3433 Web:www.sjgov.orglehd UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Applicatlon is hereby made to San Joaquin Cow ty 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 9-1 15.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 1245 W.Charter Way S.Fresno Stockton 95206 Assessors 163-230-34 <br /> WELL Location Cross Street City Zip Parcel# <br /> PROPERTY Geo Corporadon/JM (209)522-3271 <br /> Owner Equipment Addri ss 321 Spreckles Avenue City Manteca Zip 95336 Phwe# <br /> C57Contractor V&W Drilling dress 3806 Duck Creek DrivVty StocktonZip 95215L)c#720904 Phone#(209) 469-7700 <br /> Geological Technics I c 1172 Kansas Avenue Modesto n/a (209)522-4119 <br /> Consultant!Sub Cntr Address City Lidt Phone# <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> x®NEW WELL/BORING (CPT,GEOPI OBE,HYDROPLINCH,HAND-AUGER,OTHER,) a DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> JkWELL# IW-1 thru IW-4 & W-1 thru OW-3 nPRESSURE GROUT ._. <br /> a"Other GROUT SPECIFICATIONS <br /> COMMENTS: RAP Addendum dated ay 27,2011 <br /> TYPE OF WELL INSTALLATION TY E CONSTRUCTION SPECIFICATIONS See Rap Addendum dated May 27,2011 <br /> a MONITORING [$HOLLOW STEM DIA.OF BOREHOLE 15 —MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 2-4 <br /> a EXTRACTION a AIR HAMMERIDR VEN CASING THICKNESS TYPE OF CASING: a STEEL acPVC a OTHER: <br /> 'TL3�l-o surf rMIE TYPE TO BE USED: a AUGERS a HOSE <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL <br /> a AIR SPARGE/OZONE a PUSH POINT(GF or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS_„_. <br /> M OTHER:Injection& a OTHER APPROX.BORING DEPTH 25 feet $.BOLTED TRAFFIC BOX or U STOVE PIPE <br /> observation CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: See Work Plan dated 1/ /09 and addendum letter dated 4/16/09 <br /> NOTE: OFFSITE BORINGc REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WO KING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin nces, I s a d g Iations,and all applicable California State Laws. <br /> Signed x w �/ Tllle/CompanY VP <br /> Print Name_ y <br /> _.(- l/ tl� '� _.__ __ Date <br /> 1 DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRE IS: ) :2 : S W as r7fe Y WL!%ti <br /> WORK PLAN DATED: M1111 2 <br /> Application Accepled By r Date Issuetl Area <br /> Grout Inspection Bybate Final Inspection By ate,_ <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: TtA I = -Ir 0O <br /> ACCOUNTING ONLY: AID# L01 <br /> PE CODES 1. <br /> FEE INFO A�i10UNT REM ED CHECK# DATE PERMIT f SERVICE REQUEST# INVOICE <br /> 3 4 1r ers-nez o os 0�82,1SR# 006 28S331411. 00 3 02 c.c <br /> C-57_ WC=WAI&i • 0 -57 Letter of Au horiation to sign per <br /> Encroachment doc_ <br /> E024-02-001 R 0 <br /> _.2 q 7 <br />