Laserfiche WebLink
-5) <br />.111 E-L, <br /> <br />SITE <br />JAN !AFIpATI ON <br />UNrT IV <br />ENVIRONMEN <br />PEP.M!TiSc'R'.1 !C"C <br />OSan Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 />Assessors <br />WELL Location 602 North California St. Cross Street Oak City Stockton Zip CA Parcel# 139-165-09 <br />PROPERTY <br />Owner Gary Stallworth Address 602 _North California St .City Stockton Zip 95202 Phone# 209-464-1282 <br />C-57 Contractor MitChell Drilling Address 7900 Myrtle Ave City Eureka Zip95503 Lic# 672617 Phone# 707-444-9040 <br /> <br />Consultant / Sub Cntr Advanced GeoEnvironmental Address 837 Shaw Rd. Citystockton Lic# 680227 Phone# 209-467-1006 <br /> <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />ff NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />U SOIL BORING # <br />ti WELL # MW-9 <br />U *Other <br />o DESTRUCTION (choose type below) <br />U OVER-BORE. DIAMETER <br />U PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />0 <br />ci <br /> <br />COMMENTS: <br /> <br />TYPE OF WELL <br /> INSTALLATION TYPE <br /> <br />CONSTRUCTION SPECIFICATIONS <br />II MONITORING <br /> <br />if HOLLOW STEM <br /> <br />DIA. OF BOREHOLE 8" a MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: 2 <br />U EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS SCD 40 TYPE OF CASING: a STEEL B PVC a OTHER: <br />a VAPOR OMUDROTARY <br /> DEPTH OF GROUT SEAL 56 ' TREMIE TYPE TO BE USED: if AUGERS 0 HOSE <br />U AIR SPARGE/ OZONE Q PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FA/ / DEPTH IS 30') <br />U SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Portland Type II <br />U OTHER: a OTHER APPROX. BORING DEPTH 70 ' 0030LTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED NA (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />4U 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 and Regulations, and all applicable California State Laws. <br />(tA <br />Print Name Ally Colavita Date ni Pinins <br /> <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: (v o 1 Co.A^-6crItA.-tc— 5 +-- <br />WORK PLAN DATED: •12-111- o <br />Signed x Title/Company Staff Scientist/Advanced GeoEnvironmental <br />Application Accepted Accepted By c <br /> <br />Date Issued 1 I 3t ( <br /> <br />Area <br />Date 3 I o <br /> <br />Date 3 / ijo <br />Date <br /> <br />Grout Inspection By <br />Destruction Inspection By <br /> <br />Final Inspection By <br /> <br />COMMENTS! CONDITIONS. <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # SEC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />35-0', <br />3C0/ <br />ti-1-14-°P 2 e.c( 5-11 0 1/3149- SR# <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit <br /> <br />EHD 29-02-001 <br />6/22/04 <br /> <br />bS o <br />