Laserfiche WebLink
�a aUI .._moo San Joaquin County o <br /> Environmental Health De art SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.d4yQis$ 1 2009 UNIT IV <br /> Well Permit Application ENVIROW NTHEALTN <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE <br /> PS�BUi ERVrcEs <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 County Environmental Health Department. <br /> Assessor � <br /> WELL 4515 Pacific Avenue Cross Street Rose Marie City Stockton Zip 95207 Parcel# '110'-230-23 <br /> PROPERTY One McDonalds Plaza Oak Brook 60523 (630) 623-7170 <br /> Owner Mc Donalds Corp Address City Zip Phone# 1 <br /> All Well Abandonment 6626 Merchandise Way Diamond Springs 95619 44MITS9 530 644 1609 <br /> C-57 Contractor Address City Zip Lia# Phone# <br /> Consultant/Sub Cntr Advanced GeoEnvironmentai ddress 837 Shaw Rd City Stockton L!C# ^Phone# i209S467-1006 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED; <br /> a NEW WELL 1 BORING (CPT,GEOPROBE,HYOROPUNCH,HAND-AUGER,OTHER-) 8 DESTRUCTION (choose type below) <br /> a SOIL BORING# :0 OVER-BORE. DIAMETER flinch <br /> WELL# hJ�9 k aysw-2�_- 13 PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS Portland <br /> COMMENTS: `t/ verb�rCt o wt ow(r <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING I HOLLOW STEM DIA.OF BOREHOLE$V`— U MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:2-inch <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> U SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: C1 OTHER APPROX.BORING DEPTH a 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 qpARegulations, and all applicable California Stat Laws. 1� <br /> Signed x W r Title/CompanyA� �'7 <br /> Print Name `1 h Date O `?j_ 1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: a a !! z <br /> Application Accepted By Date Issued t [ Area l �✓/ <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> a <br /> S S A5...a to off-" -3 0 0 ),_ la <br /> / S R# 5�2 i <br /> C-57 V' WC <br /> __tZ-WAIVER_ C-57 Letter of Authorization to sign permitL---Encroachment doc� <br /> EFID 29-02-001 <br /> 6/22104 <br />