Laserfiche WebLink
aU San Joaquin County <br /> ,o. • c OCT 2 1 L004� q <br /> r [ �I p(��Enjvi}�r{yonmental Health Department SITE <br /> y' i j�VIR1-1,-N"`1j9V'Y''�'0.s�1��y1'eber Avenue, 3rd Floor; Stockton, CA 95202 MITIGATION <br /> _ �'gF;iAf 4'249 Fax: (209)468-3433 Web: ,vww.sjgov.org/ehd <br /> UNIT IV <br /> a .¢ Well Permit Application <br /> YN-REFUNDABLE <br /> C 0 P 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 of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location 730 C1-7Q�-,.-rte ���"«T Cross Street 1V(sra,rt City 5 h�cK t' Zip 91­zrpL Parcel#! 1--;�70 40 <br /> PROPERTY _ <br /> Owner 147.+f--- J i�verf-,we-sr"Address 8!7 5.Ce de.- City Zipff9---(- Phone#12b4} 660</ <br /> C-57 Contractor yj%-z o'-di-.7 Addressld_ F%�fthdfirecf" City-rilef I zip�ll�5Lic#?%r0g4yPhone#/9/0777--C/+- <br /> Consultant ISub Cntr C-�717dvi_ Address Phone#(an9��3�/r�"/8 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> I]NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') pKbESTRUCTION (choose type below) <br /> 0 SOIL BORING# VVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS Cure <br /> .a <br /> COMMENTS: eei c,.-,6eJ f-awa'&' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> j]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 OTHER:_U OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 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 this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signedxy' f%' � _ Title/Company doe iarc �o r:l� Cv..�s �vs` <br /> Print Name Date_ l7l?1>/d y <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: E. Chaftnpd Sf S <br /> WORK PLAN DATED:_ 1012 t Y 12.,�D�4 <br /> Application Accepted By a Date Issued O -2 2 d4 Area S <br /> Grout Inspection 13 1 L Date 9 0 Final Inspection By Date 6 - <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: 6S tr '1 -3 <br /> i <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> X502 L0. 00 66- 60- 04405-7SR# p04007G <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 /> I <br />