Laserfiche WebLink
WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MCD FIB '�(�(�E� <br /> ENVIRONMENTAL HLALTH DIVISION (PHS-EHD) u _ uy <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 JUN 2 9 2000 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described- This ap,:lication isPX�tf�'Iri rcdPvl j __�itn <br /> San Joaquin County Development TiL'e,Chapter 4-1115.3 and the Standards of San Joaquin County Public Health Services, Envirormental Health Divls;on <br /> Assessor's <br /> WELL Location 1645 Cherokee Lane Cross StreetSanguinetti City Stockton zip95205 Parcel_- 119-100-05 <br /> PROPERTY Owner CA Traction Company Address 2201 W. WashingtonCity-tockton zip 95203 Phone;�t209-466-6927 <br /> C-57 Contractor Spectrum Exp. Address 2365 Wigwam Drive CityStockton zip95205 Licz512268Phone;�209-465-8712 <br /> consultant/Sub Contractor Hydro-Env. Tech. Address 2394 Mariner Sq- Cityklameda Lic#N/A Phone510-521-2684 <br /> Suita 2 <br /> GIS Coordinates:X 4204400 mN Y 652400 mE Township 2N Range 6E Section 43 <br /> WORK TO BE PERFORMED <br /> (},?JEW WELL I BORING(CPT, GEOPROBE,HYDROPUNCH, HAND-AUGER, OTHER-) 0 DESTRUCTION(choose type belov <br /> 0 SOIL BORING# 0 OVER-SORE <br /> WELL# 1 to 3 0 PRESSURE GROUT <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> JNIONITORING �HOLLOw STEM DIA. OF BOREHOLE 8-0" MULTIPLE CASINGS?0 YES ff NO WELL CASING D A.2.0" <br /> 0 EXTRACTION S AIR HAb.1NIERIORIVEN CASING THICKNESS sch 40 TYPE OF CASING: 0 STEEL la PVC 0 OTHER. <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 10 ft TREMIE TYPE TO BE USED: 0 AUGERS :ji-i0SE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Xi Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH 1S 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 50 ft :I BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_O OTHER CONDUCTOR CASING PROPOSED? No (if YES, list specifications here): <br /> COM"AENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby cartify that I have prepared t`I:s--pplication and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San.Joaquin County. <br /> */CALLf�THE UNIT IVNSPECTOR 48 WORKING HRS IN ADVANCE FORALL REQUIRED 1NSPEC7 <br /> (/"" K./ (.(fie 4-1 <br /> 4-1rciu•Y Cltc..fL, l7Lf 1C�-- a Tri C' <br /> Signed z G-tom Title/Company <br /> �u <br /> Print Name GtI•(�« - cb" � Date 6 - <br /> �'1-J <br /> SEE SITE MAP I UNIT IV FILE WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By vv.t c 02te Issued Alea__ <br /> Grout Inspecticn BY. r _Dace1.--Z-15— Oc) Final Inspection By, <br /> Destruction Inapec6ion By Date <br /> COMMENTS 1 CONDMIONS: <br /> ACCOUNTING ONLY: A1Q# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> CO2-3Z`1 <br />