Laserfiche WebLink
aP�"'" San Joaquin County •PAYMEN LE COPY <br /> > P RECEIVE <br /> 4 Environmental Health Department SITE <br /> w 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 JAN 3 0 Z006MITIGATION <br /> F. <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> • \PSAN JOAQUIN COUNTY UNIT IV <br /> Q�rFOR" Well Permit Application ENVIRONMENTAL <br /> HEALTH DEPARTME <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 /> (p-/�.4 Assessors��G ,�..,C� <br /> WELL Location Cross Street City Stockton Zip Parcel#��/'6aZ(77L1/ <br /> PROPERTY �- F Ouck: ['/4 eke C.Sr�& <br /> Owner FJS Ranches PTP Address 2928 Dwight Way City Stockton Zip 95204 Phone# 209-463-1456 <br /> C-57 Contractor V&W Drilling Address P.O. Box 416 City Isleton Zip 95641 Li,*720904 Phone# 916-777-4100 <br /> Consultant/Sub Cntr Kleinf elder, Inc. Address 2825 E. Myrtle St.Gity, Stockton Lic# NA Phone# 209-946-1345 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> fNEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> 0 SOIL BORING1# 0 OVER-BORE. DIAMETER <br /> ff WELL# r cGU' i[H , d'tG✓'.� 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ff MONITORING gHOLLOW STEM DIA.OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 21- <br /> EXTRACTION <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS Sch 40 TYPE OF CASING: 0 STEEL If PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> a SOIL BORING aHAND AUGER GROUT SPECIFICATIONS Neat cement w/4; Bentonite powder <br /> 0 OTHER:-0 OTHER APPROX.BORING DEPTH 80' 0 BOLTED TRAFFIC BOX or EFSTOVE PIPE <br /> CONDUCTOR CASING PROPOSED NA (if YES,list specifications in comment section) <br /> COMMENTS: <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 /> Si9nedx Title/Company <br /> D�T. <br /> Print Name �-= S Date VS 40 5 <br /> DEPARTMENT USE ONLY oa <br /> H <br /> SITE MAP IN UNIT IV FILE,ADDRESS: f( — z57 -it- <br /> WORK PLAN DATED: S <br /> Application Accepted By Date Issued C/ Iy Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> "ACCOUNTINGAID# FAC# <br /> AMOUNT REMITTED CHECK# REC'D BY D/ATE PERMIT I SERVICE REQUEST# INVOICE <br /> Iffou 1�76w � t/36(o6 SR#_ — IVER_ C-57 Letter of Authorization to sign permit Encroachment doc_/ / <br /> EHD 29-02-001 �GF/JQ Z-0- � <br /> 6,22,04 U <br />