Laserfiche WebLink
Ilan Joaquin County <br /> Environmental Health DepartmentIvJLS f <br /> 600 East Main Street, Stockton,CA 95202-3029 TE <br /> JAN 1 1 zO�fTIGTE <br /> (209)468-3449 Fax:(209)468-3433 Web: www.sjgoY.org/ehd <br /> ATION <br /> lot Well Permit Application E�� UNIT IV <br /> NON-REFUNDABLE PERMIT EMRES I YEAR FROM DATE IBatfEE1 <br /> AppNcallon Is hereby meds to San Josqufn County for 8 Per"to Corstnxt and/or WON the work dwaibed. This WOCation Is made in compliance wflh San <br /> Joaquin County Devalapment TWO.Chapter 9-1]115.3 WW the Stendartls of San Joaquin County En*ow ental Haft Department. <br /> WILL LoCatlom`r lKl/� rj roes Street ` Cily (�. Zfp �� ,3 <br /> ParoeAl t7' 0 '� <br /> PImPER,Y dreea�b $� 113 <br /> t __City 4M Ptwrra# 3 <br /> Ca7C x*acW iej + IM <br /> Conwttant 1 sub Cnlr <br /> GIS Coordinrlas:X !Y :Township Range Section <br /> 0 NEW WELL!■ORING QM GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHEIn TRUCTION (dwoae '1b ^- <br /> 0 SOIL BORING f R-BORE. DIAMETER <br /> 0 PRESSURE GROUT <br /> a.0ow 1( t 0 ROUT SPEC CATIONS 64'x'"" <br /> COMMENTS: 6er ) f t / W--7 1. 41 I I :- <br /> TYPE OF WELL <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING Ow- <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL p PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS fl HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH PONT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH 18 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: II OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (If YES,list specifte ons In comment sedion) <br /> COMMEMY& <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I haw prepared this application and that the work will be done In accordance with San Joaquin <br /> County OrdiRules and4t"ulations,and all applicable California laws. <br /> Swwi x TI11e1Company kk 5r>10 <br /> Print Name MmaYN Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: S 1 S 3- 6"&4A'A' (A!M!j2 Zo <br /> WORK PLAN DATED: ! <br /> Awkeflon Accepted By L"­'% o,c_ Date 1Wu9C----L/ a/192 if Area <br /> Grout Inspection By, Dent Final Inspection By Date <br /> De*ucdon irspedion BY Date <br /> OONOMM/WAM r mm! <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK* RECD BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 35-0Z '$4&!;0,0 3 o5, 3 Af 11%he> SRO So �`'� <br /> ]] <br /> C-57 WC=WAIVER C-57 Letter of Authorization to sign permit�&-----Encroachm ent doe_ <br /> Eiw 29.02.40! WEB <br /> 9/11/2007 <br />