Laserfiche WebLink
•San Joaquin County • <br /> Environmental Health Department SITE <br /> vJl�t , 3, MITIGATION <br /> #17 , 68-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> „ Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FILE tour I <br /> Application Is hereby made to San J9q,4n�bunty for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Devve�lopmCnijltIdl..0 gAf�leor,&11115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 1�J by64 V`�, __ La 4 ,� T!G'(, ZI �3() Assessors <br /> WELL LowU.o.�n� C.�1�1Cross Street Nit lA Crity p Parcel# Zi21000 Q> <br /> OwnerE =/�.'7AA��v([L�fi�✓vt'7a� Address3511/ I I Ui/ I'�rcIAQ ��'11M City �7(,�-06 MIS ZiP�jIlo Phone# C 4 1, <br /> C-557 ConVactoAl -'Z't. Address X20 E, J'l+ City WrcI Zipj UW L j Phone#7�1/` -�J0-Z7Zq <br /> Consultant/Sub C <br /> ntr7W5 Mti%&'IAVVVVP f'Address337Xi r tai✓' l'ty`19�0' L" c#� �S�°nonze# S:fXb-G, (4—�Az z <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> '"EW WELL/BORING (CPT EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# Yr\WPI 0 OVER-BORE. DIAMETER <br /> n WELL# 0 PRESSURE GROUT <br /> p*Other GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL �IN/STALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING g�HOLLOW STEM DIA.OF BOREHOLE II Q MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> n EXTRACTION 8 AIR HAMMERIDRIVEN CASING THICKNESdSjt. 40 TYPE OF CASING: n STEEL *PVC n OTHER: <br /> n VAPOR n MUD ROTARY DEPTH OF GROUT SEAL.'7 r TREMIE TYPE TO BE USED: 0 AUGERS n HOSE <br /> n AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes [ro (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 'l% (s'3j'41d <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH 20 I n BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED nD (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 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordiiny'an'f[�,Rules and Regulations,and all applicable California State Laws. j /// <br /> Signed u^'y` A Title/Comoany ��=1/r5-1 / 51k:�s 'I�J�Ui!•'�mi'uRL�ly <br /> Print Name 5,04 17r1�•n 4�� Date��Q �S'Tln <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 4 ZS LQ rod Rn a J <br /> WORK PLAN DATED: J U 1�0 0 8 <br /> q 1 <br /> Application Accepted By V 1 C-�'Ar i r5 L 1 n'vt C 11i YTYL� Date Issued 10 -20-08 Area <br /> Grout Inspection By '1c+jrid Ml I1wr}nAdq Date f2-S• OS Final Inspection BynirYbil�tr}na.Aate /Z -9 -02 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: Z 4Yin - 2 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35,01 69.00404. 00 173Gy' �//1r1 1010 08 SRO 0055710 <br /> 35'o3 3r5•a <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 />