Laserfiche WebLink
oPa�'ry. San Joaquin County <br /> Environmental Health Department SITE <br /> �^: { 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: 209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> c 4 <br /> -'FORS Well-Ipplication <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 9-1115.3 and the Standards of S Joaquin County Environmental Health Department. <br /> 1 � sessors x <br /> WELL LocatioOaOO �r-/QrAve —Cross Street i� lr7 City ti '' 'Zip rcel# S� G J� <br /> PROPTV <br /> t <br /> � �p�'/ Gf �— "9Owner �'�Lfl AddressLOQ Iat A Citi"j�. 4WC.Zip!�u?�4hone# <br /> C-57 Contra / i ddressla� lyL[Y(Ga9 City 7Z/?Zip JZc# Phone# <br /> Consultant/Sub Cntr Q Address Citycf l Lic# Phone# <br /> GIS Coordinates:X G Y ���.2✓� Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) Xj <br /> DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# RESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS Id k` <br /> COMMENTS: �• ll � � ,i S'0i /> <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECATIONS I t <br /> AONITORING 0 HOLLOW STEM DIA.OF BOREHOLE e" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_Z_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS to Lt0 TYPE OF CASING: 0 STEEL ,PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS d.� <br /> p OTHER:_0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS:A40 C �'</I((�•-� 1 r% —Ci <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 a egulations,and all applicable California State Laws. <br /> e r 5 ) <br /> Signed x ..a/ Title/Company�TCItY M•�d ��//7 ��P` <br /> Print Name J-i //T `i Date IZ I In/DE5 <br /> DEPARTMENT USE QNLY Go, <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ll V <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Q tt« + Ar <br /> Grout Inspection By Date Final Inspection Bq a.- '� '- ate 411ffAi YK <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 30 2-- Yv /p0,� l3 ?.a G (.23A� SR# (2:� 07't�/ <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doe_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />