Laserfiche WebLink
FILE C Py <br /> San Joaquin County <br /> Environmental Health De artment ITE <br /> 304 East Weber Avenue, 3rd Floor,Stockton, CA 95202 IION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/elid UNIT IV <br /> c• __;a P .. AUG 2 6 2004 <br /> Well Permit Application <br /> ' NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIR�jjpOpppN��rM�eECNT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This appI E tVid MEFeVAG 6pliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELLLocation %9Ao N. W\LF4#, TH eD Cross Street RtCity STeaKTbW Zip Parcel# OB 7-4g0 -2V <br /> PROPERTY <br /> Owner GAAy SCt,wNP vlNo Address 5#A63 CkkSVWKEEQO. City STocKt-en1 Zip9'6215 Phone#(z69) 451- 3579' <br /> C-57Contractor_496Ctpvvt EX FLCRATRkr Address ;A5 WIGWAM 'RD, _City S-nyXXoN Zip"%oS'Uc#St726$ Phone#(209)165-8712 <br /> Consultant/Sub Cntr Address City__"— Lic# — Phone# <br /> GIS Coordinates:X ,Y ,Township ZN Range -7E Section '72. <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> a SOIL BORT a OVER-BORE. DIAMETER <br /> MOILL# 0 PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> XAONITORING �-101-LOW STEM DIA.OF BOREHOLE Q tA. 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: ln_ <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS 5LK 40 TYPE OF CASING: 0 STEEL `jWVC 0 OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL20 jc 4t. TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 241es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Neo T C E MBF1T <br /> 0 OTHER:_a OTHER APPROX.BORING DEPTH-Mo-tee s T-T• 0 BOLTED TRAFFIC BOX or :04TOVE PIPE <br /> CONDUCTOR CASING PROPOSED V O (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 /> `"INl -(+- � <br /> Signedxl l.J,,-df. A� A l Title/Compance ASSoc1�rES <br /> Print Name t-l\cHAe-L. Arjtig: 4gow Date Au&NST zy, tooy <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRE <br /> WORK PLAN DATED: 9'n <br /> Application Accepted By Date Issued t _/tea Area <br /> Grout Inspection By Date Final Inspection By Dale <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# C'D BY DA PERMIT/SERVICE REQUEST# INVOICE <br /> 3.�7 �, : L Xa, SR#oa s <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to Si4n permit_IiI6 Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />