Laserfiche WebLink
�oaa�'•"..�o *..6an Joaquin County (o <br /> Environmental Health Depart0�-# /', SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 9p5��202 D MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgoV Qy/eVd5 2004 UNIT IV <br /> Well Permit Application ENVIRONMENT HE <br /> AL <br /> P=b/SEf3 VICES TH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE <br /> Application is hereby made to San Joaquin County for a permit to construct and/pr 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 SanJoaquinCounty Environmental Health Department. <br /> A <br /> WELL Location Cj`C l r 5�1 fcc'-� Cross Street J � ssessors <br /> -city ac<.v�,� zp95 3e Parcel# <br /> PROPERT LL G7 <br /> Owner_ .�err,�' 9b(� Address J -I I f.Shr - City 5jxNA-AL'``Zip b33ikPhone# 'Xq "g�5-�'75d <br /> C-57 Contractor *nnLQ II CAQ ress ? 61,) 3,3 0 City D ('��-" , Zip 7 I Liic#7- 10b-4q 707-3�{-'V360 <br /> Consultant/Sub Cntr_�1DQX t�Y1J�(y�GC Z ddress 1(2LAL! + jy� L,)& Cityl�OtAl�(�12i' Lic# �10( I Phone#91/O"[Y�JI-D/7 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> )p(NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> *WELL# rj a PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> -- I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS A <br /> a MONITORING ,HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> o EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS&V% D (- TYPE OF CASING: a STEEL PVC a OTHER: J <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL ZD-pct,/ TREMIE TYPE TO BE USED: AUGERS a HOSE <br /> $AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes WNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS T -.- 1U. Ce_,MQA� <br /> a OTHER: 0 OTHER APPROX.BORING DEPTH rj Meet 30LTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PRbPOSED (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. {�y� iI <br /> Signed x /�i Title/Company T ksx ew LIZD—FEC4, Tw'. <br /> Print Name l/h _-ry 1 May+(n!n Date r f— �) I?4 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS. A7 S6� � � CA <br /> WORK PLAN DATED: _jk -7 /�✓t� a� - Gr�m�l< l'lu �,� Qwn� �'ydl�iry // <br /> Application Accepted By d� k Date Issued Z b 2 -Area <br /> Gy11163'' <br /> Grout Inspection By ,�Ly Date 1YFinal Inspection By Date /Z / <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3So I µw 89 ° a�S C.tir,� SR# oo14O S 4 6 <br /> C-57 P"" WC WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />