Laserfiche WebLink
PQM San Joaquin County ��CIFIV ELS <br /> a` _ �y Env><ronmental Health Department g 2007 SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 9520 MITIGATION <br /> fY <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.or@9�AOUIN COLIN UNIT IV <br /> ENVIRONMENTAL <br /> <P HEALTH DEPARTMENT <br /> `�<<FOR? 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 ofSanJoaquin County Environmental Health Department. ssessors <br /> WELL Location 260 00 S•,i ATA )W • Cross Street W -1iJ/�E kY FAA G� ZiP �� U Parcel# Z.SL 16-0.-06 <br /> PROPERTY I r ,�,,f�// 9 L SJD7 <br /> Owner �`�I�L SOSS�1110n1 Address31p2tQ/� �1C57 tNi diity—Q�����p�)��( Zip �y�Phone# 2 7 Q <br /> C-57 Contractor �'kUY b�[•W�d A�d-dre,rss//J(/ 7 fUYV L' �k' C�tYJ�L iP </ '�"# Phone/#� �r pJl . •S2U�� <br /> Consultant/Sub Cntr S6t0� �NrlLli �l/�N��I ressS Q 1 Cityjjd!f J�Lic# Phone# / '�7% ' vJ�O X� <br /> 3�•YLZ'1��`I ,Y,���• 59�%, P }� Section <br /> GIS Coordinates:X Townshi Range <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION (choose type bel //++����� 5C, <br /> , <br /> SOIL BORING# OVER-BORE. DIAMETER 1d��Z <br /> 0 WELL 4f 0 PRESSURE GROUT <br /> 0*Other z GROUT SPECIFICATIONS <br /> COMMENTS:� -i ' WE" A/44 E,114 1{,T � 1 G`i•`5 / �' aMFiTtI�- Z j1IA��iI.f� D �1 Z0I S <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 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 O0 OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> THER: <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 a d Regulations, and all applicable California State Laws. <br /> T IelC3mpa.y <br /> JIlJ.11C11 A <br /> �'� Date <br /> LA ! S�U <br /> Print Name CI <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: D D <br /> WORK PLAN DATED: <br /> Application Accepted BY0 k Date Issued 7�I / Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By _ Date /D 07 <br /> COMMENTS/CONDITIONS: V Q <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> v � 6a bat <br /> 2,1 2'L lux- ��( SR# 11Z <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />