Laserfiche WebLink
ED <br /> San Joaquin Count <br /> z� o0 6 2010 Environmental Health Department SITE <br /> East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> 'ENT 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> SE? ' <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 /> 814 E.Charter Way Grant Street Stockton 95207 Assessors 167-181-01 <br /> WELL Location Cross Street City Zip Parcel# <br /> PROPERTY Rashad Hussain(RP <br /> Owner Frank Morita) Address 3525 Canyonland Rd City Stockton Zip95209 Phone# (209)478-7546 <br /> C-57 Contractor V&W Drilling Address 3806 Duck Creek Drive City Stockton Zip95215 Lic#720904 phone#(209)469-7700 <br /> Consultant/Sub Cntr Geological Technics Inc Address 1172 Kansas Avenue City Modesto Lic# n/a Phone# (209)522-4119 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: MW-1 thru 4, 7, 104, 107,&202 <br /> Q NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) N DESTRUCTION (choose type below) <br /> Q SOIL BORING# -AOVER-BORE. DIAMETER 8 4,o lo" <br /> Q WELL# APRESSURE GROUT <br /> Q*Other GROUT SPECIFICATIONS 04,01 PotNa4 C cA A.+ <br /> COMMENTS: See Work Plan dated 1 �2�t1� 0V.& t% uww-I rl-�4}? _pry>� l,c wk twtw-�,3�41 t ��zo, ob <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: )r.AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS +)4r-a►Ir C)orlrl a w� t,¢-�M�I.Wj" <br /> Q OTHER: Q OTHER APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: See Work Plan dated <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 prepare this application and that the work will be done in accordance with San Joaquin <br /> County Ord' R es n Rulations, and all applicable California State Laws. <br /> Signed x 1 Title/Company C M1� 'J 02)M �7ecihol cs <br /> Print Name I 1 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: B(4 C fJk'aV24� <br /> WORK PLAN DATED: atm Tk 7ro11 t <br /> Application Accepted By Date Issued 3 1 Area 36 <br /> Grout Inspection By Date Final Inspection By Date 4(TiX( ti" <br /> Destruction Inspection By ate -1i t L <br /> COMMENTS/CONDITIONS: &1X- 4).- ( 1 <br /> ACCOUNTING ONLY: AID# FAC# <br /> ECODESFEEINFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ��`� o I3�Z. ,-- v��►Z� ��Z3�1� SR#s- >-q5-S5- <br /> C-57✓ WCC-WAIVER_ C-57 Letter of Authorization to sign permiil:—� Encroachment doS-,---' <br /> EHD 29-02-001 <br /> 6/22/04 <br />