Laserfiche WebLink
is 0 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sogov.org/ehd <br />WELL PERMIT APPLICATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <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 />650' of Newcastle Rd along NCYCC Assessor's <br />Well Location S. Perimeter Road Cross Street Newcastle Road City Stockton Zip 95215 Parcel # 181-150-08 <br />Property Manteca 95336 209-982-4298 <br />Owner Forward Incorporated Address 9999 S. Austin Road City Zip Phone # <br />C-57 Contractor Precision Sampling, Inc Address 2365 Wigwam Drive <br />Consultant/Sub Cntr Herat & Associates, Inc. Address 4630 S. Hwy 94 - N. Outer Rd. <br />GIS Coordinates: X 6359714.18 <br />Y 2146438.92 <br />209-465-8712 <br />City Stockton Zip 95205 Lic # 636387 Phone <br />City St. Charles Lic # Phone 636-939-9111 <br />, Township 1 North <br />Range 7 East Section 34 <br />WORK TO BE PERFORMED: <br />INSTALLATION TYPE <br />m NEW WELUBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ SOIL BORING# <br />❑ OVER -BORE DIAMETER <br />0 WELL # AMW-21 <br />❑ PRESSURE GROUT <br />❑ *OTHER <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />m MONITORING <br />❑ HOLLOW STEM <br />DIA. OF BOREHOLE 8 -inch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 2 -inch <br />❑ EXTRACTION <br />❑ AIR HAMMER/DRIVEN <br />CASING THICKNESS Sch 40 TYPE OF CASING: ❑ STEEL m PVC ❑ OTHER <br />❑ VAPOR <br />19 MUD ROTARY <br />DEPTH OF GROUT SEAL 0-149 TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE <br />❑ AIR SPARGE/OZONE <br />❑ PUSH POINT (GP OR CPT)_ <br />GROUT SEAL PUMPED: QJ Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />❑ SOIL BORING <br />❑ HAND AUGER <br />GROUT SPECIFICATIONS 7 x 94# Portland cement: 100 gal. water <br />❑ OTHER: <br />❑ OTHER: <br />APPROX. BORING DEPTH 175 ❑ BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: <br />OFFSITE BORINGS REQUIRE <br />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 �//2l.��__ Title/Company Project Geologist, Herst & Associates, Inc. <br />Print Name David A. Vasbinder Date � Z -5 f0 F, <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY <br />DATEISSUED <br />GROUT INSPECTION BY FINAL INSPECTION BY <br />DESTRUCTION INSPECTION BY DATE <br />COMMENTS/CONDITIONS: <br />AREA <br />DATE <br />ACCOUNTING ONLY: AID # <br />FAC # <br />PE CODES <br />FEE INFO AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />PERMIT/SERVICE # <br />INVOICE <br />S R# <br />C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />EHD 29-01 11/5/07 WELL PERMIT APP <br />