Laserfiche WebLink
r <br /> San Joaquin County <br /> .Q Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> gL�Fs¢a Well Permit Application <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 /> Assessors <br /> WELL Location 3&14- Zv �Ck• Cross Street Ze0/�4' �``k, City �15k Zip 952d�, Parcel# 177-27-027� <br /> PROPERTY �1 / / l Ave. 0C4,223 <br /> Owner I,UC�cf//ln L 1') C c (obP Address 2Gfj� �:.4 tuc" ACity Zip 96(3(2 Phone# 46' 2-43'�� <br /> C-57 Contractor 6W4,4-befl!!A Address /5& FIOJtoe- R6kkCity CJ 7Zipy4- h4 �Lic#48-''i�f�hone#92~j -3t3•- <br /> /Sub Cntr A Address 2112( N,C` ��t� ek ���C't b' AJ9 U� ic# p , _3 t' L' Phone# �--` <br /> ConsultantP RticlaS f � � .-_.iY �� �ir `�Z j4-1-I Az <br /> GIS Coordinates:X 'Y Township Range rp C Section 173 <br /> WORK TO BE PERFORMED: <br /> "EW*;EL-H BORING (CPT,GEOPROBE,HiYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> ' ,SOIL BORING# �- 16 �C P•T ) 0 OVER-BORE. DIAMETER <br /> 0 WELL# T—T 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS AHOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: `(Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 50'4z, 116 + 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ^,� I CONDUCTOR CASING PROPOSED 114 C+ (if YES,list specifications in comment section) <br /> COMMENTS: SEk� uPC�wI 2C,, 7QL4 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that I ha pr ared this application and that the work will be done in accordance with San Joaquin <br /> County 0dn ce R ulations, and all applicable Californian State Laws. <br /> Signed x - Title/Company <br /> Print Name Date "Z D <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By - 'lam 53,&� Date Issued —Area T <br /> Grout Inspection By Date Final Inspection By Cdr,, ba^C� Date l 1 fi� <br /> Destruction Inspection By Date <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 /> ado l 1001� 50� )&A SR# 4 <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment clot_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />