Laserfiche WebLink
oPa"'•_"`._C' n Joaquin County <br /> P2 Environmental Health Departme2�� SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 9 ITlGATlON <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ 3 1 2009 UNIT IV <br /> Ct r P <br /> Rt;9bit Well Permit Application <br /> ENUIRONMENT HECA�LiTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE lss MIT/SERVICES <br /> Application is hereby made to San Joaquin County for a permit to construct andlor 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 /> 4500 Pacific Avenue/Fronta Rose Marie Stockton 95207 Assessors <br /> WELL Location %toss Street City Zip Parcel#. <br /> PROPERTY <br /> Owner City of Stockton Address 345 North Elborado StStocktonStockton Zip 95202 Phone# 937-8561 <br /> All Well Abandonment 6626 Merchandise WayDiamond Springs9S619484359 530 644 1609 <br /> C-57 Contractor Address CityZip Lic# Phone# <br /> Consultant I Sub Cntr Adyj%nced G ro.Exy-in Address 837 Shaw Rd City Stockton Lic# 6so227 Phone# (209)467-1006 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) $DESTRUCTION (choose type below) <br /> a SOIL BORING# fl OVER-BORE. DIAMETER—8 inch/12 inch <br /> D WELL# Jyt ✓���� ►�rw f3_kwl>t yM.wld,�y►+wh��yrl�? $PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS Portland <br /> COMMENTS; bUrrdrEll -� Il�gt��IY�wI�. c ��ro..f' Nnwr� �Kc tGnc.,!'T n.k. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> (MONITORING �e HOLLOW STEM DIA.OF BOREHOLE_" ff MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 2-inch VVV <br /> If EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: G STEEL G PVC G OTHER: <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> p AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> OTHER: a OTHER APPROX.BORING DEPTH 0 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 Ordinances, Rules anq Regulations, and all applicable California State Pws. / 1 <br /> 'Signsdx Title/Company <br /> Print Name2 Date 19 be <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: t ( f <br /> WORK PLAN DATED: l <br /> Application Accepted By —Date Issued It f Area G Z <br /> Grout Inspection By Date Final Inspection ByZ�LDate <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> zJ un�3� �� r!a SR# �S 2 <br /> o � <br /> C-57L_ WCT WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc� <br /> EHD 29-02-001 <br /> 6/22104 <br />