Laserfiche WebLink
San Joaquin County <br /> '. Environmental Health De artm '��(�E��I <br /> -+ P ��11� SITE <br /> "� 304 East Weber Avenue, 3rd Floor, Stockton,CAZiI� MITIGATION <br /> « '=' (209)468-3449 Fax: (209)468-3433 Web: wvsw.sjgov.or <br /> - l , 6 UNIT IV <br /> Well Permit Application , i 1 TEAL <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSf7Fq,1. i/6"'MV10ES <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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department, <br /> WELL Location_t.��....�.}o„T^f. � Gross Street E\ Do�A- City S�oc k�.� Zip g SZoy Parcel#Assessors <br /> PROPERTY 'q'l O J� Q S� q <br /> Owner C.>c o f S��c�.t�r. Address�3 S N (Zr.s t, City 't oa+ova Zlp`i5 z,z Phone# 2, <br /> C-57 Contractor Address \(3\\o £"' Yc ¢,\kq{1. City .wi1.t,A—,Zipg-L Lic#e_j1ys`�BPhane# 1��I' 9 3 - IOc�So <br /> ns /6ab Entr Address 1N�11 k­ S Citvlo Lic# Phone# L01 S <br /> GIS Coordinates:X_ - ,Y ,Township___ n Range Section <br /> MRK TO BE PERFORM; <br /> 13 NEW WELL/BORING QKP GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER") p D TRUCTION (choose type below) <br /> 16 SOIL.BORING# C- <br /> Q WELL# o OVE BORE. DIAMETER <br /> p-Other a PRES E GROUT <br /> GROUT SP IFICATIONS <br /> COMMENTS: <br /> T n OF.WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING E]HOLLOW STEM DIA.OF BOREHOLE p MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: _ <br /> (I EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: p STEEL a PVC a OTHER: <br /> AL <br /> 11 VAPOR a MUD ROTARY DEPTH OF GROUT SETREh11E TYPE TO BE USED: a AUGERS Q HOSE <br /> 1)AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> p SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> 13 OTHER: I1 OTHER APPROX,BORING DEPTH _ _ _ a BOLTED TRAFFIC BOX or d STOVE PIPE <br /> C CONDUCTOR CASING PROPOSED (if YES,fist specifications in comment section) <br /> COMMENTS: 'P 3:)a��g.,A, 3 ,l S-.'ZS <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 Sart Joaquin <br /> County Ordinances I ' nd Regulations, and all applicable California State Laws. <br /> Signed x Title/Company a 6'7L"`T �Ijt�t <br /> Print Name sl-'a-Uc A L f Dated Jp <br /> DEPARTMENT USE ONLY <br /> SITE MAP 1N UNIT IV FILE, ADDRESS: <br /> WORK FLAN DATED: <br /> Application Accepted By �• Date Issued. . 6 / , (mow Area <br /> Grout Inspection By + / Date_ Z at Inspection By Date <br /> Destruction Inspection By1;7- J Date J <br /> COMMENTS l CONDITIONS: <br /> ACCOUNTING ONLY: •AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DA7 PERMIT/SERVICE REQUEST# INVOICE <br /> SR# 44,52 <br /> C-57 WC—WAIVER,_ C-57 Letter of Autho zati to sign permit Encroachment doc <br /> EHD 29-42-ool <br /> 6/22/04 <br />