Laserfiche WebLink
- <br />SITE <br />MITIGATION <br />UNIT IV <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95262 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgoworgiehd <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ORIGIN <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. Assessors <br />WELL Location 320 2- E. 144,44E12 Cross Street ET 1E5 77.0- PLOity S:TOCTO") Zip 1.521 Parcel# <br />11E1) City /4 cks z1pq5317phone# 26 577-06,17 PROPERTY <br />C-57 Contractor Gesa.s 3)41(-4-0,-/&" Address Z7 Z' tJ'u1 CityS Zip90753—Lic# YYS-1Phone# (s-if24.-) yz:740819 <br />Consultant / Sub Cntr 1;41. Address 301.7 ri(00 eLt Oci Lio# Phone# lIfilUt'e)(100 <br />CO e-rkf <br />GIS Coordinates:)( 7O OS. J 4Ny I 2,1° /V J''1/, TtowlnistIpu Range <br />WORK TO BE PERFORMED: <br />ONEW WELL / BORING (CPT,6E0 <br />0 SOIL BORING # 643:7,4q2-,44&" <br />El WELL # <br />[I *Other <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE " a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC a OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />0 AIR SPARGE/ OZONE) (PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes 0 No1rTE: AXIMUM FREE-FALL DEPTH IS 30') <br />N <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH <br /> 1...3,-,n- <br />.5 1 0 BOLED TRAFFIC BOX or a STOVE PIPE SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br />CONDUCTOR CASING PROPOSED (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 />Signed x Title/Company <br />c. <br />DEPARTMENT USE ONLY <br />Area <br />Date <br />Owner TU/4 4" 7. j4 (1 ip Address 33 )40 R 2 /Pi Tra-I P <br />Section <br />PROP HYDROPUNCH, HAND-AUGER, OTHER') fl DESTRUCTION (choose type below) <br />0 OVER-BORE. DIAMETER <br />PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />Print Name <br />Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: 3 -7O e e <br />WORK PLAN DATED: <br />1-\,,A,--0(-1- • Application Accepted By <br />Grout Inspection By Date <br />Destruction Inspection By ate <br />COMMENTS / CONDITIONS: 4 <br />0 <br />Date Issued <br />Final Inspection Inspection By <br />ACCOUNTING ONLY: AID# FAC# <br />INVOICE <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # <br />zcit. -611. <br />C-57 WC .-WAIVER <br />EHD 29-02-001 <br />6/22/04 <br />SR# 04\ t <br />C-57 Letter of Authorization to sign permit Encroachment doc <br />nv