Laserfiche WebLink
.�• u�" � Joaquin uin <br /> jSan q County <br /> A 60onvironmental Health Department uLn�l �i SITE <br /> East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/eh UNIT IV <br /> `� �+ � zoos <br /> P , <br /> . Well Permit Application <br /> ENVIROl�NIENT _� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDPERM SE T "�RVICES <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 04 L(4ti-2 Cross Street b�41JWVVj City 5I,4 �+ Zip $S%uq Parcel#rsU-77 IVuc)- <br /> PROPERTY <br /> Owner ( � U' v1 Address Z1 �/�r<�+� C1 . T ' p. s 3 <br /> City ""t`i Zi `� Phone# <br /> T"` <br /> C-57 Contractor Li'JA W4,4 blod�`4_Address tis o kvf,r Rvtf Cit K'd UI'l� �Y 71 7�(1 G 7 �0 7-374-43w <br /> I !! y Zip $ Lic# 1 Phone# <br /> Consultant/Sub CntrU+�ryIwLQhi Address5so ) <br /> 33}U CstN,r.o t ��k Qv City ruvnQ+oK Lie# Phone# L` l <br /> GIS Coordinates:X ��S �Z <br /> Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> B NEW WELL 1 BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*)! g'DESTRUCTION (choose ty6be )B SOIL BORING#B WELL# OVER-BORE. DIAMETER <br /> B'Other B PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: w <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> *ONITORING HOLLOW STEM DIA.OF BOREHOLE {0„ -0 MULTIPLE CASINGS B L WELL CASING DIA:___ <br /> B EXTRACTION B AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: B STEEL B PVC BOTHER: <br /> _ <br /> 11 VAPOR B MUD ROTARY DEPTH OF GROUT SEAL C�S 1 TREMIE TYPE TO BE USED: GAUGERS B HOSE <br /> B AIR SPARGE/OZONE B PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 'Yes B No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> B SOIL BORING B HAND AUGER. GROUT SPECIFICATIONS VVk`+� ctyu to <br /> B OTHER: B OTHER APPROX.BORING DEPTH fa�1 B BOLTED TRAFFIC BOX or B STOVE PIPE <br /> CONDUCTOR CASING ROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> 1 14F <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> ,1 <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> Count in s Rules and Regulations,Y � g s, and all applicable California State Laws. <br /> Signed CJ Title/Company <br /> Print Name '0"' � Date 3/3 1/-0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: _14,12 1-6rt l _1�gps-e_ 01 r r n Q <br /> WORK PLAN DATED: _311xfoa 1 gleam WWI I <br /> Application Accepted By Date Issued D Area <br /> Grout Inspection By Date rd O`er Final Inspection By Date D.1' <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 I SERVICE REQUEST# INVOICE <br /> 160-3-0 S'R# <br /> G-57_ WC -WAIVER C-57 Letter of Authorization to sign perM t-j,/Encroachment doc� <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br /> �i <br />