FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

WELL PERMIT APPLICATION FORM SITE SAN JOAQUIN COUNTY MITIGATION ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV 304 E. Weber, Third Floor, Stockton, CA., 95202 (209) 468-3449 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department Assessors WELL Location 7500 West t l th,St./Chrisman Rd. Cross Street n/a City Tracy ZIP. 95304 Parcel# public road PROPERTY OwnerSan Joaquin County Address 1810 East Hazelton CityStockton Zip 95201 Phone# (209)468-3000 C-57 ContractorSpectrum Exploration Inc Address 2365 Wigwam Drive City Stockton Zip 95205 U0 512268 phone# (209)465-8773 Consultantt I-Snb-eantractvr 'rhe San Joaquin Company Inc. Address 1120 Hollywood Ave ##3 City Oakland Lic# GE882 phoaL(5 to)336-81 18 GIS Coordinates:X 121.Deg 23 Sec 54 Min W Y 31 Deg.44 Min.24 Sec N_ Township 2 South Range 5 East Secfi 22 T WORK TO BE PERFORMED; NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, OTHER-) ?e I ❑ DESTRUCIlQN(choose,type below) ❑ SOIL BORING# LI OVER-BORE ® WELL# wells in public highways 3 ❑ PRESSURE GROUT 'Other Specifications: COMMENTS: See Work Plan for Extended Site Characterization 7500 West Eleventh Street,Tracy,California dated October 2001 by The San Joaquin Company Inc.for well locations TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATION,§I ® MONITORING ® HOLLOW STEM DIA.OF BOREHOLE: 8 m•_ _ ,MULTIPLE CASINGSIO YES I@ NO WELLCASING DIA: 2 in. ❑ EXTRACTION ❑ AIR HAMMER/DRIVEN CASING THICKNESS 0.1 in, TYPE OF CASING❑STEEL®PVC❑OTHER: ❑ VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 3' TREMIE TYPE TO BE USEO® Auger ❑ Hose ❑ AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ❑ Yes ® No(NOTE:MAXIMUM FREE-FALL DEPTH IS 30') ❑ SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS: Elentonite/Type II Portland cement ❑ OTHER. ❑ OTHER APPROX BORING DBE TH 22' ® 13OLTED TRAFFIC BOX or ❑STOVE PIPE CONDUCTOR CASING PROPOSED? No (If YES,list specifications here)- COMMENTS: See Work Plan for Extended Site Characterization 7500 West Eleventh Street Tracy,California, dated October 2041 by The San Joaquin Company Inc.and supplcmenial letlerdated 11/29/01 on rile with San Joaquin County Public Health Services for individual well construction details NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County Ordinance , Rules and Regulations, and all applicable California State Laws. Signed :rifle/Company Geotechnical Engineer,The San Joaquin Company Inc. Print Name avid J Watkins r ate 28 Feb 2002 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: WORK PLAN DATED: Application Acoepted B ` ' r ate Issued m 0.. r�r- C-o ZD OZ Grout Inspection By e U Date Final Inspection By _ Ji aL Date i Destruction Inspection By 42 Dat COMMENTICONDITIONS r✓ a— D h WO Q a Ir Q D o1C ACCOUNTING ONLY: AID# W EACH L>rryt, PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY PATE PERMITISERVICE REQUEST# INVOICE -350 ( 1 �, oo 2 G57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doe 1/25102 i