Laserfiche WebLink
Stan Joaquin Count [',�IJWEID <br /> Q` Environmental Health DepartmentAILIG 0 4 2006 SITE <br /> < 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgoj-�It�,6�NMENT HEALTH <br /> . � • .�' oEf-iF�IT/SERVICES UNIT IV <br /> F0�� 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 andtheStandards of San Joaquin County Environmental Health Department. <br /> FCCritc J kr ee( e�cy y(�o-� / -RID( Assessors ,I <br /> WELL Location Cross Street�<(4TI)) e City S�-alrC��'1� Zip 9' Z©6 Parcel# (7-7-0&-14- <br /> PROPERTY 77-0&-1"f <br /> PROPERTY G� <br /> Owner C. S�C f t ub(:C �c�ress 34� �. DD a o City S�OILJ&44 Zip' �Z !Phone# 2/ r9) CI -'334- / <br /> C-57 Contractor dJ�(l O le!61dress 9�& � nw(-C KOR1 City MRl��'T ---zip 9 066 is#49-\-)6g-one#qZ5 313 S�DO <br /> Consultant/Sub Cntr a�g Address 2l2(N.(q� �(�`ci W�/JI L�'� Q 63:3L:3� <br /> l <br /> „ � aty uc Phone# 925 X41-3' ©p <br /> GIS Coordinates:X Y Township Range G, Section z?j <br /> WORK TO BE PERFORMED: <br /> ),'NEW WELL/BORING (CPT,GEOPROBE,HYDROOPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> )KSOIL BORING# I p��h/ P (G4 0 OVER-BORE. DIAMETER <br /> 0 WELL# []PRESSURE GROUT <br /> 0*Other / // GROUT SPECIFICATIONS <br /> COMMENTS: 'sill (-< t /� ,1QefRCQfI�a fblc�/D �l[?tE L __ <br /> LVW <br /> w e <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z” 0 MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL - -,(I fo LGX&TREMIE TYPE TO BE USED: []AUGERS HOSE <br /> 0 AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 9yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTHIS 30') <br /> VSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER: [l OTHER APPROX. BORING DEPTH 56/ fv /DCS 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> f CONDUCTOR CASING PROPOSED N C (if YES,list specifications in comment section) <br /> COMMENTS: Sf�s� µrti� A04015( Zcse61 <br /> NOT OFFSITE ORINGS REQUIRE ACCESS AGREEMENT OR NCROACHMENT P RE IFITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPE NS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinan es, <br /> ,Rul `d Regulations, and all applicable California State Laws. <br /> Signed x ( Title/Company �rGheS d GeC��ri.�`S P�4 fall S <br /> r � <br /> Print Name } i•� y�ri �c C. kl V��� Date��L+ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: �J l <br /> WORK PLAN DATED: (� <br /> Application Accepted By ` a(. Date Issued F 2c06 Area <br /> Grout Inspection By Date 2-! I t7 3 Final Inspection By Date_ <br /> Destruction Inspection By Dateil,T- 'S <br /> COMMENTS/CONDITIONS: ? `` a Q rn1" Cd✓SYS <br /> ACCOUNTING ONLY: AID# Un C a� S>`oC kJy\ FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 0 19ct009 WV04 , 6 S R# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authori ati n o sign permit_Encroachment doc_ <br /> 6/22/ <br /> 04 15 oz-oo l �D n _ q��k s �a <br /> / 2 _ 15 7 / -3 <br /> CPT 163)��� � a��","1 /tel 1 � � a I - a-3 � �-a o � <br />