Laserfiche WebLink
SAN JOAQUIN COUNTY FILE CG?Y <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> r SITE <br /> �t 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> UNIT IV <br /> WELL PERMIT APPLICATION 0 r W-D <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 /> 393 E. French Cam F Ash Road French Cam Assessor's <br /> Well Location P Cross Street City P Zip 95231 Parcel# 19314012 <br /> Property <br /> Owner Gillit, Calvin&Gail Address 393 E. French Camp Roac city French Camp zip 95231 Phone# <br /> C-57 Contractor ECA Address 3011 Twin PaImS Dr. city Aptos Lic# 69597CPhone 8316628178 <br /> Consultant/Sub Cntr Stantec ConsUlti Address 3017 Kilgore Road Suite 1C66i(y Rancho Cordo, ic# Phone 9168610400 <br /> GIS Coordinates:X 37-881 Y -121.267 Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER*) ®DESTRUCTION(CHOOSE TYPE BELOW) <br /> [:]SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑`OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> W <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3 ❑MULTIPLE CASINGS®MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS 1/4 TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ®VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 5& 12 TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE M PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> Signed 1 I2 Title/Company Stantec Consulting Corporation <br /> Print Name Bryan Rorie Date 12/2/09 <br /> DEPARTMENT USE ONLY A� L <br /> SITE MAP IN UNIT IV FILE,ADDRESS: T v • �J� /`moi <br /> WORK PLAN DATED: v �O <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> C-;A- ZZ3 r �/- R#W1 ZZ <br /> 7 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br /> FILE '7"Y <br />