Laserfiche WebLink
o ul Wan Joaquin County <br /> Environmental Health Departmen������g2� SITE <br /> L9 600 East Main Street, Stockton, CA 95202-302 v CIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application SEP 0 4 2009 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS IROA�NI(7T/�EE��NpTT11'H'(rE�A��L++TH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describe N)SISIiC'afibM�S' L 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 /> WELLLocation 1943 Fremont Street Cross Street Wizard Ave City Stockton Zip 9520 Parcel# 141-090-ql <br /> PROPERTY Community Bank of <br /> Owner San Soaouin Address 22 West Yokuts Ave CityStockton Zip 95207 Phone# (209)956-7000 <br /> Advanced <br /> C-57 Contractor GeoEnvironmental, Inc.Address 837 Shaw Road City Stockton Zip 952 Ligf680227 Phone# (209)467-1006 <br /> Advanced <br /> Consultant/Sub Cntr GeoEnvironmental, Inc. Address 837 Shaw Road City Stockton Lio# 680227 Phone# (209)467-1006 <br /> GIS Coordinates:X - ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> H NEW WELL/BORING (CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') g DESTRUCTION (choose type below) <br /> H SOIL BORING# B-2 & B-3 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: Reference AGE-prepared Limited Subsurface Site Assessment Work Plan, dated 01 September 2009 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 1_25"0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: u/n <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 25' or 40' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE g PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> H SOIL BORING B HAND AUGER GROUT SPECIFICATIONS Type I/II neat cement <br /> 0 OTHER:-0 OTHER APPROX.BORING DEPTH 25' or 40BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (if YES,list specifications in comment section) <br /> COMMENTS:Reference AGE-prepared Limited Subsurface Site Assessment Work Plan, dated 01 September 2009 <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x_ _ Title/Company Vice President/Advanced GeoEnvironmental, Inc. <br /> Print Name Robert E. rty Date 01 September 2009 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, A DRESS: <br /> WORK PLAN DATED: a �9 <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By [/LSA4,,Apv� Date Final Inspection By Date_ <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> c, 3004SSR# s$Z$Z <br /> C-57_ WC_WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />