Laserfiche WebLink
San Joaquin County <br /> } )Fnvit mental Health Departmett SITE <br /> =ry < <br /> 600 E.Main Street, Stockton, CA 95202-3029 MITIGATION <br /> E <br /> W(L rax: (209)468-3433 Web: www.sjgov.org/ehd UNIT 11/ <br /> �•..�-•=.may <br /> R` V 0 9 2007 Well Permit Application <br /> ENVIRONMENT HEAp{iLREFUNDABLE PERMIT EXPIRES 4 YEAR FROM DATE ISSUED <br /> Applica0on is hPER $� A �Q�t�iintCounty for a permit to construct and/or instail the work described. This application is made in compliance with San <br /> Joaquin County Develop en M01,t 11'Ater 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> r .� fr Assessors <br /> WELL Location���7 7 Pae r�iC L�'q Cross Street WrK,rn f,c1, City � c o '1 Zip y 2� Parcel# 4 %74�8'b!C/ <br /> r } In <br /> Ow4erER ►d�5 (Jr Address r 3if!� �'+ E✓k'1 'N City aK r FC ��'✓ZYp!_ Phone#5? <br /> 2--6 J�_2l j p � <br /> C-57 Contractor y lir Address/o/6 L.�4, Ci(A 4 City_jAIL�.¢�wti Ziptz�cij Lic#jPhone# <br /> Consultant I Sub Cnlr6,4)-40;c (11-50"Address5712 go15g City Phone# 7/�/�9f`is7�7 - <br /> GIS Coordinates:X J01I0q,3j rrlv_,Y ri l d q� 7.q1 wtj,Township Range Secilon <br /> WORK TO BE PERFORMED: r+�err— nn yl"i(/VLJ 1?V5 <br /> U NEW WI=LL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, OTHER" XDESTRUCTION (choose type below) <br /> []SOIL,BORING# 4 <br /> OVER-BORE, DIAMETER_ + r�P_ IQ� <br /> (]WELL#_ Q PRESSURE GROUT <br /> 'Other GROUT SPECIFICATIONS <br /> COMMENTS: IV4'S4 's w,(I bAe ✓f-s ✓aK Q wr}t. cv+, <br /> � ed' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [i MONITORING -,IR-IOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL.CASING DIA; <br /> EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: []STEEL 0 PVC 0 OTHER: <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS p HOSE <br /> a AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> [I SOIL BORING it HAND AUGER GROUT SPECIFICATIONS <br /> [I OTHER:_0 OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or t7 STOVE PIPE <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 pplication and that the work will be done in accordance with San Joaquin. <br /> County Ordinances Ru es and gulations,and all applicable California State Laws. <br /> Signed x- 2�' Title/Company <br /> Print Na e_('0V .-0 df�t�CrLt�.�r Date / f 6 1'aT <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �� lb u_Z0 <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued to `o Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date/ 2 <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3552, d�j v ? SR# © ��2 �)�' <br /> C-57WC-V--WAIVER__ C-57 Letter of Authorization to sign permitz Encroachment doc <br /> EH D 29-02-001 web <br /> 6/22104 <br />