Laserfiche WebLink
an FILE COPY <br /> JoaquinQunay <br /> Environmental Health D�partm -�i� v�L��J SITE <br /> { 304 East Weber Avenue 3rd Floor, Stockton CA 95202 <br /> lOOb MITIGATION <br /> w <br /> (209)468-3449 Fax: (209)468-3433 Web: ww.sjgov ork/ei;i l ' UNIT IV <br /> Well Permit Application ENVIR(:i'1v.1t ':\H HEALTI <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS919410T,!SERVICES <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 /> Assessors �9 <br /> WELL Location 1Y�_ ( 1�<- Cross Street �/ City Stockton Zip Parcel# Z.91-0 Q 140 <br /> PROPERTY <br /> Owner Edward Lagorio Address 2343 Pinasco Road City Stockton Zip 95215 Phone#209-931-0732 <br /> C-57 Contractor V&W Drilling Address P.O. Box 416 City Isleton Zip95641LiC#720904 phone#916-777-4100 <br /> Consultant/Sub Cntr Kleinfelder, Inc. Address 2825 E. Myrtle St.City Stockton Lia# NA Phone# 209-948-1345 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFOt1MED: <br /> 9NEW WELL/BORIN(a (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) a DESTRUCTION (choose type below) <br /> U SOIL BORING# a OVER-BORE. DIAMETER <br /> a WELL# M Gl a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ff MONITORING [:HOLLOW STEM DIA.OF BOREHOLE 8" a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 2��__ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS Sch 40 TYPE OF CASING: a STEEL a PVC BOTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [:AUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING aHAND AUGER GROUT SPECIFICATIONS Neat cement w/4E Bentonite powder <br /> a OTHER: B OTHER APPROX.BORING DEPTH 80' a BOLTED TRAFFIC BOX or [:STOVE 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 La s. <br /> Signed x ��✓/ Title/Company Z� , <br /> Print Name ���fLf_C� Date OZ//AQ <br /> DEPARTM NT USE ONLY Q <br /> SITE MAP IN UNIT IV FILE, ADDRESS:—E• O'34- Xot <br /> WORK PLAN DATED: f <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Da(e <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ZQ� Ljr7l fi 00 SR# 66415-1-yo?' <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to 5i9A permit_ Encr ment doc_ <br /> END 29-02-001 Q.rC�JJ <br /> 6/22/04 <br />