Laserfiche WebLink
• • <br /> � FILE COPY <br /> 'OPp,Uri Cp San Joaquin' County <br /> Environmental Health Department 11)� <br /> CA 95202 � SITE <br /> �• � 304 East Weber Avenue,3rd Floor, Stockton, <br /> MITIGATION <br /> (209)468-3449 Fax: (209) 468-3433 Web: www.sigov.MAH 13 AM I I: 2yNIT IV <br /> Foa��� Well Permit Application SAN ;Ua(; ;_� (;OUN7Y <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISJ&y Ip 0i'411t NT A L <br /> T I I I)F PAA <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This app ic �{Tn compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location �' Cross Street r-' XWJI City �MK, _Zip Parcel# <br /> Ro <br /> I1 ( I (� ' 2 / � l <br /> OwnerER ,o�� � )^ k YV 1 �) �N ivl ri-- _City WW ip� Phone#� Z/ <br /> d1�i Address r; .-�5 <br /> C-57 Contractor oN i Address C� L S Cityl��lb/r�t�c t ZipirVntic# 1/ 1 Phone# LL �j `�ti6U <br /> Consultant/Sub Cntr Address t u1 �µYL� Phone#�-� -[ # <br /> GIS Coordinates:X 9a Section- <br /> Y ,Township Ran <br /> WOjRK TO BE PERFORMED: <br /> EW WELL/BORING (CPT EOPROBE,HYDROPUNCH, HAND-AUGER,OTHER*) tiDESTRUCTION (choose type below) <br /> Q SOIL BORING# COVER-BORE. DIAMETER <br /> WELL# U PRESSURE GROUT <br /> 1]*Other GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE_ n MULTIPLE CASINGS g MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: C STEEL U PVC D OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL (;p I TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> C//AIR SPARGFJ OZONE ,®GUSH POINT(GP or P GROUT SEAL PUMPED:XYe�No (NOTE�MAXIMUM FREE-FALL DEPTH IS 30') <br /> �Q'SOIL BORING E HAND AUGER GROUT SPECIFICATIONS <br /> �a OTHER:_0 OTHER APPROX.BORING DEPTH (11 , p BOLTED TRAFFIC BOX ,or 0 STOVE PIPE <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 hereb4certify hav�repared t ' application and that the work will be done in accordance with San Joaquin <br /> Countu s and Reg ions and all applicable California State Laws. /Signedx Title/Companyj iA Rril,,�I,./' (b`t�Print Na <br /> Date d <br /> DEPARTMENT USE ONLY <br /> pf� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> i <br /> WORK PLAN DATED: / <br /> Application Accepted By (�O` Date Issued 6 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK# REC'DBY DAT PERMITISERVICE REQUEST# INVOICE <br /> �o 91-- 3Z 3 SR# Dd <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encr <br /> EHD 29-02-001 <br /> 6/22/04 <br />