Laserfiche WebLink
`',in Joaquin County <br />Enviro..mental Health Department <br />600 East Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />FAC# <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 />FEE INFO <br />Joaquin County Development Title, Ch�apteL9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />5• a' P""r.6" '> ` <br />CHECK # <br />Assessors <br />WELL Location City of Stockton Right of way Cross Street Fifth Street City Stockton Zip 95206 Parcel# �vy <br />DATE PERMIT I SERVICE REQUEST # <br />PROPERT�ity of Stockton 345 N. E1 Dorado St. (209) 937-8266 <br />Owner Address City Stockton Zip 95206 phone# <br />C-57 Contractor Gregg Drilling Address 950 Howe Road City Martinez Zip 94553 Lic# 656407 Phone# (925) 313-5800 <br />zir�'2 0 <br />n <br />Consultant/ Sub Cntr 4�l vctna Eitc�n�ir.,Uge7� Tess 33� S hc;xi IV City >`n&l0zzl Lic# W*L,-12_�- Phone#(ac;�)yG } 4c, <br />GIS Coordinates: X Y Township Range Section <br />2l t o� R#c70s'j 1� <br />WORK TO BE PERFORMED: <br />03 <br />x,,TNEW WELL / BORING (�Fp� (f OPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />xg SOIL BORING # 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 'Other GROUT SPECIFICATIONS <br />One off-site CPT to total depth of 120'. <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1201 TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE .10 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />:8 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Type II Portland Cement <br />(� <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 120' 0 BOLTED TRAFFIC BOX or 0 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 Ordir� nces, Rus and Regulations, and all applicable California State Laws. <br />Signed <br />Print Name <br />Title/Company <br />nate <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 1 t J t S- r— ( J)o'wI, 5 C— <br />WORK PLAN DATED: II -- Off/% l `Ly o` -- <br />Application Accepted By �i"� Date Issued Area 1 <br />Grout Inspection By Date Final Inspection By Date n <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT I SERVICE REQUEST # <br />INVOICE <br />B1.00 <br />zir�'2 0 <br />s`f <br />2l t o� R#c70s'j 1� <br />03 <br />-16-4v <br />C-57 WC L" -WAIVER <br />EHD 29-02-001 WEB <br />9/11/2007 <br />C-57 Letter of Authorization to sign permit I/ Encroachment doc <br />