Laserfiche WebLink
• • FILE COPY <br /> G:q0( •Do SAN JOAQUIN COUNTY <br /> Q ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> u MITIGATION <br /> r� <br /> � �DD Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.siaov.orG/ehd UNIT IV <br /> AUG 2 6 2009 WELL PERMIT APPLICATION p G <br /> EiVVIRONINIENi iiEALTN NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I'4 I�r]'1 Sle 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 oun eve opment Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> AssessoIqO W 6� yC AVelk City 5-6 E.E81n Zip g52o& Parcel#r I63 '�O-I} <br /> Well location 1 u Wa ross Street Vto ¢- <br /> Property DlL�IIl T„, -& -� *, g9rp 1� <br /> Owner t kr (rD1011 dress 1 1 I-City �tlla5 Zip jZ { Phone# 2 -�i <br /> C-57 Contractor i (IIVt Address jISO �06WO RA City N I ��Lic# �ahone ern-1�'li�'QgA3' <br /> Consultant/Sub Cntrlf WJR,ddrests 17J?i M l & Mill 11, SIC.toll City ND Lic#�Phone 26y-2 3o <br /> 2 <br /> GIS Coordinates:X -►• 3 ,Y. —11Z I.31( ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> A NEW WELL/BORING(CPT,GFpPRRSh H��ROPUN H,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> %SOIL BORING# J D�+� ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑`OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> C <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE 3" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> O AIR SPARGE/OZONE PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes Ell INo <br /> (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 94 SOIL BORING El HAND AUGER GROUT SPECIFICATIONS wY1W/Nf1��L, TOr �(�jr-fr� <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH SIS tGGT ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE ] <br /> ^� ( e CONDUCTOR CAS NG PRQPOSEfI ifi ES,listEpenhcatlona in comment cGon f <br /> COMMENTS: SD 1ip t9 �Li1 �`jjf <br /> I"> <br /> - NO�: eFFSI E RINGS REQUI E ACCESS AGREEMENT OR ENCROACHMENT PERMITS (/ <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that Yfiave prep ed this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,a is 1 appJ Ica f do ia�Laws. <br /> Signed ( ` Title/Company <br /> y 6/ ✓ <br /> Print Name 1 a[e <br /> 1, 0 DEPARTMENT USE ONLY/y�'�. <br /> SITE MAP IN UNIT IV FILE,ADDRESS: q / . Y, r""— W I��oi->`•i-7 <br /> WORK PLAN DATED: •aC <br /> APPLICATION ACCEPTED BY DAAt `fl AREA O VH/ <br /> GROUT INSPECTION BY FINAL INSPECTION B ` wy DATE R'1 h09 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMT REMITTEDCHECK# iBY DATE PERMIT/SERVICE# INVOICE <br /> Zqo .s8 Z Zsv1 o Z <br /> C-57 i WC W -WAIVER C57 LETTER OF AUTHORIZATION TO SIG ER IT ENCROACHMENT DOC <br /> EHD 2&01 11/5/0](WEB) WELL PERMIT APP <br />