Laserfiche WebLink
OPY <br /> U1 �o San Joaquin County <br /> Environmental Health Department SITE <br /> a' 304 East Weber Avenue, 3rd tRen, $2P MITIGATION <br /> tg <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sj,gov.or cad UNIT IV <br /> d.. P Well Permit A °, ENDTAL <br /> o <br /> ALTH DEPARTHEN�� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS D <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 9-1/115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Salle-Z& y� p Assessors <br /> WELL Location � Z&/,'?--Cross Street /Cil c�r—� Zi Parcel# y ' q <br /> PROPERT��/, CityGo- Zip�Phone#2�- GCJ6.0 <br /> Owner(%T Address�6�J�n 6��'�C <br /> C-57 Conlractor� AddresAb Rix JV6 City r i _Zip <br /> / <br /> Consultant/Sub Cntr� Lisc U/ Address.2XZ���0W'� City S Lic# Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION (choose lygg below) <br /> 0 SOIL BORING# OVER-BORE. DIAMETER J <br /> DWELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS, <br /> COMMENTS: 'I <br /> ' Ti>rw•6 +20 - s <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ D 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: ❑OTHER APPROX,BORING DEPTH 0 BOLTED TRAFFIC BOX or I]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 /> Signed x Title/Company <br /> Print Name Dale LL. <br /> ZZ DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: C q ,y���y.�/J <br /> Application Accepted By Dale Issued J�J Area (�fP'-' <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> 11 ACCOUNTINWONLY: AID# FAC#PE CODESAMOUNT REMITTED CHECK# REC'D BY DATE PERMITI SERVICE REQUEST# INVOICE <br /> g60. SR# �t�2 737 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br />