Laserfiche WebLink
low <br /> WELL PERMIT APPLICATION FORM U,� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) O <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 �� <br /> (209) 468-3449 � 1\Q� <br /> NON-REFUNDABLE PERMIT EXPIRES'I YEAR FROM DATE ISSUED Q <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 wilt, <br /> San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Otv.„c- <br /> AssessoI <br /> WELL Location 1645 Cherokee Lane Cross Street Sanguine t t i City Stockton Zip 95205 Pas's of f9-100-05 <br /> PROPERTYOwner CA Traction Company Address2201 W. Washington citAtockton Zip 95203Phone--209-466-6927 <br /> ga <br /> * c-57 Contractor Transglob al Env. Address 11350 Monier Pk Pl CityConrcdhoova Zip95742Lic# 70656*hone 916-853-8010" <br /> Geochemistry , lameda N 510-521-2684 <br /> Consultant Sub Contractor Hydro—Env. Tech Ad.dress2394 Mariner Sq cftA Lim �A Phone# <br /> Dr. , Suite 2 1 <br /> GIS Coordinates:X 4204400mN . Y 652400mE ,Township 2N Range 6E Section 43 <br /> WORK TO BE PERFORMED <br /> J3 NEW WELL 1 BORING(CPT. GEOPROBE, HYOROPUNCH, HAND-AUGER, OTHER-) 0 DESTRUCTION (choose type belo:r+ <br /> aSOIL BORING# 1 to 6 0 OVERBORE <br /> MWELL# 1 to 3 Ig PRESSURE GROUT <br /> Other: Six borings by Stratipro e <br /> * C57 Contractor for GW wells: Spectrum Exploration Inc. , 2365 Wigwam Drive, <br /> COMMENTS: Stockton, CA 95205, Lic #512268, 209-465-8712 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )0 MONITORING R HOLLOW STEM DIA. OF BOREHOLE 8.1 MULTIPLE CASINGS?0 YES $NO WELL CAST. G DIA 2.0't <br /> 0 EXTRACTION 0 AIR HAMMERIDRIvEN CASING THICKNESS soli;. 40 TYPE OF CASING. p STEEL AKPVC 0 OTHER <br /> 0 VAPOR 0 N1UD ROTARY DEPTH OF GROUT SEAL 10 ft TRENIIE TYPE TO BE USED: 0 AUGERS 7JH0SE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: IJYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> (SOIL BORING 0 HAND AUGER APPROX. BORI VG DEPTH 50 ft 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_O OTHER CONDUCTOR CASING PROPOSED? Nc) _(if YES,list specifications he*. <br /> COMMENTS: Six soil borings by direct push; three ground water monitoring wells by <br /> hollow stem auger- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Law u'es <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance the work <br /> for which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hirin <br /> contracting signature certifies the following: -I certify that in the performance of the work for which this permit is issued,I shall employ persons su41ect to <br /> WORKERS'COMPENSA TION Laws of California" <br /> WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> CALL THE UNIT IV INSPECTOR 48 . <br /> Title/Company Western Reg Manager, Hydro-Env. Tecfn- :2-1c­- <br /> Date <br /> x � � <br /> Date G Z) <br /> Print Name William E. Motzer - <br /> RK PLAN ;DATED: .lune 9, 2000 <br /> SE_E SITENAP, IN UNIT IYWO , -_ _...... .._.._ <br /> _ DEPARTMENT USE ONLY <br /> Application Accepted By l-t�t� Date Issued � �/O U Rrea <br /> Grout Inspection By U� �ihn � _Date �� UC: Final Inspection By � Lrn c•—, Date /`/ G�' <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> RPECOOES <br /> MFEEINFO <br /> AID# <br /> AMOUNT REMITTED CHE7�! jREC'0 BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> Ova3Z�t � <br /> 1/18/2000 <br />