Laserfiche WebLink
�oPRu' oo _ San Joaquin County <br /> Env., amental Health Department •.✓ no <br /> " { 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 � <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.sigov.org/ehd <br /> CRLIFOR�`P AUG <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT <br /> �I�fRQ I F Fit-ALTH <br /> PEF MfTco 11 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made inn cm l <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department, i with San <br /> �t� c� Assessors r r <br /> WELL Location__3021 S. EA U0'140 Sf , Cross Street . L t s.City� �Vl Zip LEI�3 Parcel# / r l 04 <br /> --&0 j <br /> PROPERTY" <br /> Owneryem memo" Address 3b% S C-1 'Dornko S{ City ARA Zip %U Phone# 2— <br /> C-57 <br /> C-57 Contractor ( AS C � Address Q 750 �� ��S��u���td Wv►�va�2ip O SQic#7��SJ�Pnone#S 2 fZ�s/�4 <br /> Consultant/Sub Cntr�1lQLiEA CIAGI\V, Address s5 s��City rl Lic# (o 22--? Phone# (00 fr <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> -"EW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# <br /> 0 WELL# p OVER-BORE. DIAMETER <br /> 0"Other 0 PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING t:IHOLLOW STEM DIA. OF BOREHOLE$1S 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: !e <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Se 1, q TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 163, 510' TREMIE TYPE TO BE USED: 0 AUGERS ,KHOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: NrYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING p HAND AUGER GROUT SPECIFICATIONS_ Pv�Na,•td <br /> 0 OTHER:_0 OTHER APPROX, BORING DEPTH XTC'r S' 't@!LOLTED TRAFFIC BOX or 0 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 /> 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_�Aend,>+/AAj" A �Po I ' <br /> � � � �utrau�,t,t�w"t�l.�a�c. <br /> Print Name f C�Sl,-Qr <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By ✓V _Date Issued G�(.� f{ �0 ZO O J <br /> Area <br /> Grout Inspection By Date Final Inspection By <br /> to <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# + <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D B [DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3570 $3�s 22 5 ( g �- SR# tf 2 <br /> C-57_ WC -WAIVER C-57 Letter of Authorizati o Sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />