Laserfiche WebLink
o?a`•''"�• z noME= <br /> SAN ..IOAQUIN COUNTY <br /> > 1111 <br /> ONMENTAL HEALTH DEPARTMENT <br /> - .., SITE <br /> N. <br /> JATn'erp20 a East Main Street( Stockton , CA 95202-3029 MITIGATION <br /> on 209)468-3454 Fax: 209 468-3433 Web:www.sl4oV_org/ehd UNIT IV <br /> aifFOR�. <br /> ENVIRONMENT HEALWELL PERMIT APPLICATION <br /> PERMIT/SERVICES FILE <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 applicafion is made in compliance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor's <br /> Well Location 730 L h-inA-eC Sr Cross Street / n `�I- City s�'O e a Zip 2�►2 Parcel#139-2-70 t O <br /> Property1 T- t� C <br /> pAdTn yefrl.<..ts Address t7 i 7 S:6 e City StoC t�I Zip Phone#X09 1166-81604t <br /> Owner R61Lyjh <br /> C-57 Contractor P/Yc-i S I,tA rnkAddress x-365 ��..�v✓!cAi P City S16e-/ •ths, Zip 524 tic# 36397 Phone <br /> t 5rt <br /> Consultant/Sub Cntr C-OA16,,F,r'l 421 <br /> TA�re4ss'�i_ t? �f�n�f(✓eF>r_C_T Cit ,,j1/2+� 7ai. Lic# ` 'hone 1 23 it 0s�� <br /> GIS Coordinates:X 6336336 YZ)71q ;7 7 Township �/� Range 6j6F _Section I <br /> WORK TO BE PERFORMED: 1 LLZ1 0 1 5' °56 �/g 5���23�.7-6"'` <br /> ❑NEW WELL/BORING(CPT,G�OPkh1E HY&ROP�NCH,HAADZAUGO,07HV) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ,SOIL BORING#_ _ C1OVER-BOREDIAMETER <br /> �°VUELL# ? C1 PRESSURE GROUT <br /> OTHER VA par- G r � GROUT SPECIFICATIONS <br /> T^�^T <br /> - C ,❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: n 'O 7': SP / �✓ 3-for �✓ 7 C+�r <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 10MONITORiNG 0'tiOLLOW STEM DIA.OF BOREHOLE _� ❑MULTIPLE CASINGS 0MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS g.,M- TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ;2<APOR ❑MUD ROTARY DEPTH OF GROUT SEAL !F �RErAIE TYPE TO BE USED 0 AUGERS�'HOSE <br /> #8 <br /> IT Pr,r 2H►w�T ford cU E L� <br /> ❑AIR SPARGEIOZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUAPED�'Yes NO {NOTE:M 1MUI F 3 (F LL DEPTH IS 30') d <br /> SOIL BORING Ja HAND AUGER GROUT SPECIFICATIONS n!-,� C[I., T` <br /> � r u n <br /> El OTHER: ❑OTHER: APPROX.BORINGG DEPH '1 7J BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED M (if YES,list specifiWtionS 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 I accordance with San Joaquin County Ordinances,Rules and' 1 <br /> Regulations,and all applicable California-La s. �} <br /> Signed TitlelCampany, 0__641nr4 <br /> eLlg/`r <br /> Print Name 181A A �nani Date iex <br /> .DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS <br /> : 3 0 e e <br /> WORK PLAN DATED: ,Jana r y 15, .2 0 1 0 6 <br /> APPLICATION ACCEPTED�BfY V I j', i a r4'1/1 <br /> te;"a L. hAe.Cid r:'n e v DATE/ISSUED -3 Q — Q_ AREA I S <br /> GROUT INSPECTION BY 11 r.�Dtim mE1 �r�r�[ rn FINAL INSPECTION BY Y E ditDriE mtY�1¢r�rDATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITEONS: 5 5 2 Y S V- �S <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES F E INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> t 'o o x.34 Od llg8 `��12 3--8-/D SR#005g444, <br /> C=57 WC :WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 1D/2W09 WELL PERMIT APP <br /> n <br />