Laserfiche WebLink
I! 4 <br /> San.Joaquin County � "M <br /> t Environmental Health Department ITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 JAN 1 4 201MITIGATION <br /> ' (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.occ/ahf�ONMENT HEARIT IV <br /> Well Permit Application t��PVERMIT/SERV <br /> ICLS <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> .� Application Is hereby made to San Joaquin County for a permit to construct andlor install the work described. This applloatlon is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards ooffSonn'.Jioaquiin County E/nvironn-mental Health Deppartment. p <br /> WELL Location 1�5�D Narl�vyl (� Cross Street J J r/'CZ7 Ciy 1 A 1�'V01/1 Zip �J�ParceM{rs I i / I�fv'0 Z <br /> PROPER ,p Y"1.7C— I/�I (� <br /> Owner Y` P/U Address I5.761 S, o(VIa-l- I`Gt City q ! ZiPj5_b_LPhone# k -7s/ Y 4z(' f <br /> C-57Convactor_01 bi'MI A A••d��drlIessllo P. CUJi St, n Ciy l'✓�(w.0. ZiPgn76 Uc#t' A34 Phone#_)) p6k-1414 f <br /> Consultant/Sub CnV ]rvlyi/J'1 J/u'm'jiAdtl eiss-3530 N1 fh>7 P�,k �' #$5u Gt,nDr�n jJl,�/f q G L <br /> a itY <br /> ti .GIS Coordinates:X ,Y ,Township - Range Section <br /> g iS NYORK TO BE PERFORMED: (1l e 4Giv / 1„j��` <br /> p NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) �t DESTRUCTION (choGoose`type be sw) <br /> a SOIL BORING# /rfl OVER-BORE. DIAMETER <br /> J]WELL# RESSURE GROUT / <br /> g*Other GROUT SPECIFICATIONS fLO UII'anl <br /> COMMENTS: IWO- is 11`A LV_1 fi IfEp <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS E <br /> 0 MONITORING p HOLLOW STEM DIA.OF BOREHOLE_ n MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> g EXTRACTION g AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: g STEEL <br /> 0 PVC U OTHER: <br /> a VAPOR g MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: g AUGERS u HOSE <br /> g AIR SPARGE!OZONE g PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> L g SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: D OTHER APPROX.BORING DEPTH g BOLTED TRAFFIC BOX or g 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 /> l'.herebyCertify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County 0rdin rifles Rules and Regulations,and all applicable California SSt�ate) Laws. <br /> Signed x SLf9' l (1 I TttMlCompany (/"u b' I SI —)"_5 <br /> _5 <br /> Pnnt Name_> �(n�l)I t'�I^�t Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I S.9bd Nrnn-L<k P—a <br /> WORK PLAN DATED:__ IvA <br /> Application Accepted By�, n^_Gr-- -Date Issued Z� I z.!I O Area Rq� <br /> -Grout Inspection By Date '' /q Final Inspection By Date <br /> Destruction Inspection By DateV/C? 1�01 D <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> c, .PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> `35'c7z `los toe Z lea (t� z ro(l� sR# 5 `1333 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />