Laserfiche WebLink
r %,an Joaquin County <br /> QP�uin! -.o � <br /> Environmental Health Departmek011�',]'VkSITE <br /> 600 E.Main Street, Stockton,CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.orgA#j 0 2 2003 UNIT IV <br /> Well Permit Application ENViRONW-NT NEA <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSLP&RMIT/SERVIGES <br /> Application Is hereby made to San Joaquin County for a permit to construct andfor Install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter <br /> 9.1115.3 and the Standards of San Joaquln County Environmental Health Department, <br /> b'T� ( Citcic4�v, Zi O Assessors ,t <br /> WELL Location_ Q r 'C 1,ICA,&P Cross Street►fit da+rA y p Parcel#_ ��T O C' <br /> PROPERTY !1 t�,, <br /> Owner e,#ryl _—_—Address 1'311(- rfrt I.( Hwy Cily`k^tn�¢S¢r,ry iP-1 Phaneil b29?J35t3� Pscf3257 <br /> �J <br /> C-57 Contractof- 'I` t.11,.� Address 10lk, 0.kE+.lA&d City,�7ip`�z�i L€c#,�,��Phonedt J c) <br /> Consultant/Sub CntrGe,ll�dLT�S.fAddre savt2txa City� GLtc# G�S2L Phone#�/' 6Q652 - <br /> GIS Coordinates:X 1801101-31r, _,Y I° Township Range 5ecilvn <br /> It.t>11 —124--24ki <br /> WORK TO BE t <br /> E W WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') • I]DESTi RUCTION (choose type below) <br /> '$SOIL BORING# Ja p OVER-BORE. DIAMETER <br /> •WELL# rC�P U PRESSURE GROUT <br /> ii'Other �4 ,� GROUT SPECIFICATIONS <br /> COMMENTS: • eW1va-II W- � I► W- r <br /> TYPE OF WELL INSTALLATION nn CQN§MMC-nQN SPRCIFIRATIONS DIA eA. <br /> 'jl(MDNfCORING ri&A <br /> HOLLOW 5TL�M DIA.OF BOREHOLE_ IA MULTIPLE CASINGS O MULTI-LEVEL WELL CASIN DIA: <br /> .EXTRACTION a AIR HAMMERIDRIVEN CASIINw. Hl�tTESS SL, �o TYP5O��F-yASING: u STEEL VC a OTHER:_ <br /> II VAPOR MUD ROTARY DEPTH D tNR? T&EAL'tz T EMIE TYPE TO BE U ED: ©AUGERS 0 HOSE <br /> a AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPE6: ,XYes a No (NOTE; MAXIMUM FREE-FALL DEPTH IS 301} <br /> SOIL BORING Ii HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 5113 ..77 V (]BOLTED TRAFFIC BOX or AWOVE PIPE <br /> CONDUCTOR CASING PROPOSED AID ,(if YES,list specillcatlons In comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify/that I have prepa;d th plication and that the work will be done In accordance with Sart Joaquin <br /> County Ordinances,Rules and R atlons,and all applicable California State Laws.J�/ <br /> &grted x -!�" ' T1tIelCampeny L r"+AAAAd�- 1jt'S1'Ih- *;'At'eA br4a.r..r t <br /> Print N e e cels♦+« a+tirt��tt->� —Date r47-� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: y t <br /> WORK PLAN DATED: 12 :27-0 7 <br /> 4 <br /> Application Accepted By Data Issued / Are <br /> Grout Inspection By Date CbFinal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC* <br /> P$CODES FEE INFO AMOUNT REMITTED CHECKS REC'D BY 'DATE PERMIT I SERVICE REQUEST* INVOICE <br /> 150 $9 ZFb Get ►-i-mP SRO 053ZSI <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to Sign permit Encroachriltan a doc <br /> -49 <br /> EHD 29.02.001web <br /> 6122104 <br />