Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> 3 ENVIRONMENTAL HEALTH DEPARTMEN I SITE <br /> 600 East Main Street, Stockton , CA 95202-3029 MITIGATION <br /> Telephone: (209) 468-3449 Fax: (209) 468-3433 Web; wwws' ov. 13 <br /> WELL PERMIT APPLICATION d"Y <br /> 7 �illt7 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE I"TRVIR01vioT <br /> Application is hereby made to San Joaquin County for a permit to. construct and/or install the work described. This applif ictQ.(' (rygQe / 1 C¢ µlth San <br /> Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Dep /// JJJ I ES <br /> Assessor's S <br /> Well Location 1901 South El Dorado Street Cross Street Fifth Street City Stockton Zip 95206 Parcel # i6s-888-19 <br /> Property <br /> Owner MATAR , MOHAMMAD S & WAFAAddress 1901 S . EL DORADO ST City STOCKTON Zip 95206 Phone # 209 - 948 - 2619 <br /> C-57 Contractor All Well Abandonment Address 3809 Pleasant valley Rd City Placerville Lic # 848359 phone 9DD - 949 -1355 <br /> Consultant/Sub Gntmdvaneed cecEnvlrooment Address 837 shave Road City Stockton LIC # 95225 Phone 800-511-9300 <br /> G18 <br /> - - <br /> GIS Coordinates: X Y Township Range Section <br /> WORK TO BE PERFORMED: _ <br /> ® NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') ❑ DESTRUCTION (CHOOSE TYPE BELOW) - <br /> ❑ SOIL BORING# ❑ OVER-BORE DIAMETER <br /> 0 WELL # MW- 5 , NW- 6 MW- 7 , Mw- e , Mw- 9 ❑ PRESSURE GROUT <br /> ❑ "OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ® MONITORING EI HOLLOW STEM DIA OF BOREHOLE 8 " ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 2 " <br /> ❑ EXTRACTION ❑ AIR HAMMERIDRIVEN CASING THICKNESS Schd . 40 TYPE OF CASING: ❑ STEEL ® PVC ❑ OTHER <br /> [] VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEAL 16 - 9 o '. TREMIE TYPE TO BE USED ❑ AUGERS F3 HOSE _ <br /> ❑ AIR SPARGE/OZONE ❑ PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: El Yes ❑ No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑ SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS Portland Type II <br /> ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 40 - 105 ' ® BOLTED TRAFFIC BOX OR ❑ STOVEPIPE <br /> CONDUCTOR CASING PROPOSED No (If YES, list specifications in comment section) <br /> COMMENTS: installation of on-site through W-9 for the groundwater inveotigation at QNSIM . 1901 S . 81 Dorado of . , Stockton. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 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 pplicable C ifo is Laws. <br /> Signed ./ Title/Company Project Scientist <br /> Print Name Ally Colavita Date 04 / 28 / 10 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: y L � O (. fir( �2ra1l <br /> WORK PLAN DATED: - A S t �3 <br /> APPLICATION ACCEPTED BY DATE I SUED S ( r) AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE ( <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID # FAC # <br /> PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE PERMIT/SERVICE # INVOICE <br /> J <br /> SR# ooboodv _ <br /> C-57.'G WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 219--01 1115M7 (WEB) WELL PERMITAPP <br />