Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> EMM ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> �QQ$Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.si ov.ora/ehd MITIGATION <br /> g UNIT IV <br /> ENVIRONNIEN FHEALTH WELL PERMIT APPLICATION /� <br /> PERS?IT�RERVIr F, O /4uj <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 application is made in compliance with San <br /> Joaquin County Development Title,chapter 9-111`5.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Well Location��U �QS� C�Lt�( S Street 5A/7 J6CC City <br /> it l ZiG/j C Assessors f�� <br /> Prope LL,,� ll y</�— f �/ Parcel# l v <br /> Owner hz ;VQ1x--f h 6/oy� Address O�V c v t�hS4v, � City Cry,'n Cir 4ip O7 0/ (, Phone#92La26- 40oo <br /> C-57 Contractor,i CSk✓+rn 'S41'S41tu Address t}V F<s.+ City Lic#453 Phone !�:{4 ab---)Gd L <br /> Cons u Itant/Sub Cntr p CC, AddressT34F/ /44..V City 124/t4v»& Lic Phone 7C)7 <br /> 24 'SOU <br /> GIS Coordinates:X . I�5 Y �I� r ^ <br /> � t� ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDRO�INCH,HAND- UGER OT ER*) El DESTRUCTION(CHOOSE TYPE BELOW) <br /> C SOIL BORING# A'- J — P,-3& - 4 L��o'LUJ h 6 D o nys [IOVER-BORE DIAMETER <br /> C]WELL# ❑PRESSURE GROUT <br /> ❑'OTHER ''`` ./_ GROUT SPECIFICATIONS <br /> COMMENTS: N Awb IY7'Z3D• <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE / yy II <br /> ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA'v <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 7M TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE I3PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:grYes ❑No (NOTE/:MAXI UM FREE-FALL DEPTH IS 30') <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS eor�(Gt.l tt Q k)'1 Q/-t <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH of , ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. IMACTC-C Signed Q � Title/Company Ofojgj- O l ueiQ G/ <br /> Print Name 6 0. Date Thr <br /> ,,ll DEPARTMENT USE ONLY �- 5_6 <br /> SITE MAP IN UNIT IV FILE,ADDRESS(. r6N�& c <br /> WORK PLAN DATED: d Q <br /> APPLICATION ACCEPTED BY DATE ISSUED O AREA <br /> GROUT INSPECTION BY FINAL INSPECTION B % DATEQ-549 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DAT PERMIT/SERVICE# INVOICE <br /> 2RO S 5 K&5 m#065Z37 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCRO CHMENT DOC <br /> EHD29-01 11/5107(WEB) XWZuap <br />