Laserfiche WebLink
PQ��N San Joaquin Court <br /> ' eh De iment SITE <br /> Environmental Health art <br /> P <br /> F" 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.org/ehd J = UNIT I <br /> Well Permit Application uCF:,. . <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> / v . <br /> Assessors <br /> WELL Location/y��t� �° 69�LGVj (2d• Cross Street iTl � City /��(t►1'r�V1 zip�� Parcel# �—02 <br /> PROPERT. 6 Vl /SIS D ,� -716•— Z-Z-0� <br /> Owner Jt� CIVICS CC. Address(o! ��•�yTCitYS �'� Zip Phone# Z�1—� 1 <br /> L (6-10 S7 `f i�72 i Z- c1—� <br /> cr t c� <br /> C-57 Contractor I-<'I ivtif E I I r Address Z� C:. 1�(ar""!�� StCity <br /> i) �L�(f ''Zip Lic# Phone#� <br /> Consultant/Sub Cntr Address CityLic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0'Other .::Z C�'v 7 n��i�— GROUT SPECIFICATIONS tJ6WvT �r <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS or <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLEE'0 MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: �+ _ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL kVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL !�s-"I TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 9 N (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS_AJ (a{ p pll a� <br /> OTHE OTHER `50 I!j—S. mAPPROX.BORING DEPTH i5:--' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �eZ� [-f i-P(j f- 4koe-Y` CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: I! �'1✓L' /-I�?i f h >��� S <br /> (VOTE: 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 Regua ' s, and all applicable California State Laws. <br /> Signed x //// ,^i`._� ' Title/Company <br /> �n nn A r /� � /!? <br /> Print Name (JAt++�1l l� �� 1 r✓E� /} Date l_ T <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: t -V5 o X�so��� - <br /> WORK PLAN DATED: ;:.ci°,� p� <br /> Application Accepted By <br /> Date Issued $ On' Area <br /> Grout Inspection By �N ate y- Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# F.AC# <br /> F c0rrs Fc:` -0 AMOUNT REMITTED CHECK# REC'D BY DATE 7PERMIT/SERVICE REQUEST;# IINVOICE <br /> �apl__� - �D >1 `Sf�oa( <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 />