Laserfiche WebLink
K <br /> San Joaquin County <br /> Environmental Health Dep rt <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 9802 <br /> MITIGATION <br /> �^� •� (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.orgU � UNIT IV <br /> Well Permit Application ENVIRONNIENT HEALTH <br /> PERIMI T,,/SERVICES <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 /> �Inn AA C Assessors <br /> WELL Location ism � t L171t (C� Cross Street a"u%I ity P Zip 5-3oq Parcel#-20"-ygo- 14, •ui <br /> PROPERTY L JyA;t. [90 <br /> Owner CAKL ko#%tls9 Address fil[Nj GrllL ,d^fr!j V`""City_(,slj 91Vel Zipi%70 Phone# <br /> C-57 Contractor ` ;A4 AddressZ2h V. F*5t +. 1 City14 �Zi ;� 7�a Lic Z'3� Phone# 30 rp(s$-Zy 2y <br /> Consultant/Sub Cnt��A(—w1$j1 J. fOc, AddresJlfiy , AoA)Mt�'WcS"4F 'S�,4kjvvt Li,#u r^ Phone#ej09)Z3q-7 7 ZZ <br /> GIS Coordinates:X Y Township e2. 5 Range "l ` Section ((� <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORING# &Cs ft Yier[ "It) a OVER-BORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> []*Other GROUT SPECIFICATIONS <br /> COMMENTS: Dusk ip Z0 torI` 1ere� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> []VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> �AIR SPARGE/OZONE PUSH POINT(0 or CPT)GROUT SEAL PUMPED: 0 Ye WNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Yt�LA.VAN,} <br /> [] <br /> OTHER:_0 OTHER APPROX.BORING DEPTH 2401 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> nCONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: IV�.I Ct.IMG�LT A�-s47,%. koj& <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or�di ances, R le an Regulations, and all applicable California State Laws. (� <br /> Signed x 1f 4� Title/Company o,�� ` Wil (4 h ft0G, <br /> Print Name i Date (z/zyo(' <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS:--,U,3573 vv Lt n ret: <br /> WORK PLAN DATED: a— /!� a10 <br /> Application Accepted By----=, Date Issued 1�=/d —Area- <br /> Grout <br /> rea-Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> aq o SR# 49 -)q <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 />