Laserfiche WebLink
u+ San Joaquin County <br /> s Environmental Health Depart DEDUCED ;: SITE <br /> y 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov. t� O 2006 ` UNIT IV <br /> L/Foa Well Permit Application ENVIRONMENT HEALT <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE PsjBNT/SERVICES 4 <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. Y., <br /> �/ <br /> (` / Assessors; _ li <br /> WELL Location 2.3zy A I D*" S 1L, Cross Street�l AA%5 ,/r City �0 0"Zip 9520 t/parcel#f/ <br /> PROP ERT1Yj �,',� 2JZcs. - —ori,- S ity /L `I <br /> Owner RDS/' Address 3 1, I� _ AAI ,5�c lbh^ Zip 9 w hone# <br /> re Qsl/... I.. <br /> C-57 Contractor Address 9S-� k n<...1 city�l. /n ip 4 f'SfsLic#YYS Phone#925-3/3-.Sp'�0 <br /> Consultant/Sub CntrY«,/ --� T e Address iaAr/ 1 .SL City_ .&,Cw...•Lie# • Phone#707-93.�Y y�S� <br /> —_ <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> 1 <br /> WORK TO BE PERFORMED: <br /> .]cNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) F DESTRUCTION (choose type below) <br /> a SOIL BORING# 0 OVER-BORE. DIAMETER <br /> ,WELL# H 4/- �M I✓ a PRESSURE GROUT <br /> . G <br /> 'a-*Other ROUT SPECIFICATIONS_: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'MONITORING 'HOLLOW STEM DIA.OF BOREHOLE 10 n MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: y <br /> n EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS"5(47 TYPE OF CASING: n STEEL PVC 0 OTHER: <br /> n VAPOR p MUD ROTARY DEPTH OF GROUT SEAL'LS TREMIE TYPE TO BE USED:)P JVAUGERS L HOSE <br /> F AIR SPARGE/OZONE n PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes kNo (,NCS" <br /> �NQS AXIMUM F�2EE-FALL DEPTH IS 30') <br /> nSOIL BORING aHAND AUGER GROUT SPECIFICATIONS Puf <-, Gt/►.��-h <br /> r <br /> a OTHER: O OTHER APPROX.BORING DEPTH Y�OLTED TRAFFIC BOX or n STOVE PIPE <br /> It <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 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z S7� �l� • 4 Doyw\O <br /> WORK PLAN DATED: r'l <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date-- Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAQ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �So \ 5a.00 8 -("L> tiotv[d, SR# 60/4 54 <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br /> k <br />