Laserfiche WebLink
*San Joaquin County • <br /> Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 RE(�(�M� TION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/eh. U vV�C IV <br /> Well Permit Application SEP 0 4 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIr10a14�CN( at Tu liance with San <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. Thi 1" rri1 L� rriLdrrtP <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental H��Ith� ES <br /> ",� Assessors <br /> WELL Location 1943 Fremont Street Cross Street Wizard Ave City Stockton Zip 952u� Parcel# 141-090-38 <br /> PROPERTY Community Bank of <br /> Owner San Joaquin Address 22 West Yokuts Ave City Stockton Zip 95207 Phone# (209)956-7000 <br /> Advanced 1 <br /> C-67 Contractor GeoEnvironmental, Inc. dress 837 Shaw Road City Stockton Zip 9520,7 Lipt680227 phone# (209)467-1006 <br /> Advanced <br /> Consultant/Sub Cntr GeoEnvironmental, Inc. Address 837 Shaw Road CityStockton Lic# 680227 Phone# (209)467-1006 <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> S NEW WELL/BORING (CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') n DESTRUCTION (choose type below) <br /> H SOIL BORING# 13-4 & 3-5 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> O'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: m/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 B No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> $SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Type I/II neat cement <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 25' or 40' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NC (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, ADDRESS: I C1 `(3 <br /> WORK PLAN DATED: % I t I 0 -1 <br /> Application Accepted By ( Date Issued �r;z Area <br /> Grout Inspection 8y w X62 Date Final Inspection By 1A ;n r- 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 /> z aS ss�(, va 3ooF33 q SR# S g Z g y <br /> C-57A-,/ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD29-02-001 WEB <br /> 9/11/2007 <br />