Laserfiche WebLink
• • FILE COPY <br /> San Joaquin County <br /> v � Environmental Health Department SITE <br /> < <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: wwwajgov.oig/ehd UNIT IV <br /> � �� Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install.the work described. This application is made in compliance with San <br /> Joaquin County Development Tile.Chapter 9-11'5.3 and the Standards of San Joaquin County Environmental Health DepaCment. <br /> WELL Location <br /> Assessors 1 <br /> i ._, r +:_;rocs Street City '" lip Parcel# � Q/�Q 6 <br /> PROPERTY <br /> Owner ) -�..•_s rj. <br /> _. — _— _. '. . ._ZP_. _ -..Phone# <br /> C-57Connactcr tlpmss - <br /> Consultant,'Sub-Cnt ___ -_Address City_­ ;_q tic# i __Phone# <br /> GIS Coordinates —. , Y ;_.__-.Tosru`up _Range_ Section <br /> .-rT71, T — <br /> WORK TO BE FERFORMED/ —IZI,3t` fESTRUCTION <br /> pNEWWELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') (choose type below) <br /> 0 SOIL BORING# / 5 d VER-BORE DIAMETER <br /> Q WELL# /,/,/� 7y / RESSURE GROUT <br /> a-Other III/`"" //{1 GROUTSPECIFICATIONS r i�� <br /> COMMENTS: gbr'Gv !-env r <br /> O <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> :MONITORING HOLLOW STEM DIA.OF BOREHOLE ' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 'r <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ;­r TYPE OF CASING: Il STEEL XPVC N OTHER: <br /> fl VAPOR u MUD ROTARY DEPTH OF GROUT SEAL 'Z- � TREMIE TYPE TO BE USED: O AUGERS R HOSE <br /> R AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ll Yes �No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> O.SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Pit"-,t t '-• i-" <br /> Q OTHER: U OTHER APPROX.BORING DEPTH 79 tl p BOLTED TRAFFIC BOX or TOVE PIPE <br /> CONDUCTOR CASING PROPOSED <br /> _ - �r � (If YES,list specifications in comment section) <br /> COMMENTS: �� i /' 9 �f / = <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: -2-02-,5 UA. TSG <br /> WORK PLAN DATED: <br /> Application Accepted By AV Date Issued O Area <br /> Grout Inspection By Date Final inspection <br /> Destruction Inspection:ByDate L9-2 <br /> COMMENTS I CONDRIONS; <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED `7 RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> flI/ W l> (Ob. V tis(} lo-t SR 2 3Z <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc N <br /> Efimn-ouoi WEB <br /> 9111/2007 <br />