Laserfiche WebLink
r <br /> FILE COPY <br /> o. VI ' San Joaquin County <br /> Environmental Health Department II " SITE <br /> 304 East Weber Avenue,3rd Floor, Stockto -, CA 952Qi., MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov org/ehdt� c0 R'W UNIT IV <br /> Well Permit Application - ',; 'S <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 De/velopmentt/Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> !224// - J�- City �/� p Assessors <br /> WELL Location/224k/ <br /> �/ � pp CrosWs Street V Zi Parcel# <br /> OwOnerFo�w51.44w S>e&Andre ss Zo�`J 143 BIS Zp9 66IPhone Y/ -333fl <br /> II,, $+6 2y0 City OSLYr IIG q <br /> C-57 Contra <br /> �7(PlOfgrrO�¢ A/ddress95Ba (o1,� RWJ/ l;g Cyityyimcra ZipLic#7$33Z6 Phone# 53D) <br /> Consultant/Sub C//nttr�rELO3-011/L Eno. Address N// p /IJ S GTty -S ��A.ic# Phone# LD?-7yZ-OZ92 <br /> GIB Coordinates;)W- 3145110 . -121.3??q W—0fT ship Range Section <br /> WORK TO BE PERFORMED: <br /> NewEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# //�5 J J�U /y\ 0 OVER-BORE. DIAMETER <br /> iNELL# tart O �rN/I/ 'f / Q /�/oJ 0 PRESSURE GROUT <br /> O'Other r, l• GROUT SPECIFICATIONS <br /> COMMENTS: ,;bO7c 6J(P. 1 &,w &0�u///ZZ/ l,(/. F+t 4VAr77S gGrG�r�.a <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS '1, <br /> XMONITORING XIOLLOW STEM DIA.OF BOREHOLE I aI,M^ULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS�c� TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL ^IO r TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yest,0 No (NOTE: MAXIMUM Fj2EE-FA LL DEPTH IS 30') <br /> p SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS /YE EJI�r I71.S // <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH -1Z-Z!5-40 BOLTED TRAFFIC BOX orxSTOVE PIPE <br /> \ ,. c f IOIIUC OR CASIN EROPOS D S (if.YE, list specifications in comment section) <br /> \ COMMENTS: J yr <br /> NOTE: OFFSITE BORINGS R QUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certi that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or - Ices, Rule d Regulations,and all applicable California State Laws. <br /> Signed x ��J" !/7 Title/Company o E6 o i <br /> Print Name / hou+.wx L+�[1?"LF'J[ Date 2t 0 <br /> DEPARTMENT USE ONLY zp�� <br /> 'q of >/ <br /> SITE MAP IN UNIT IV FILE, ADDRESS: /ZZI <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued �--16-o�-- Area <br /> 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 /> �O / 9 g' SR# �50�53 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc NIA <br /> EHD 29-02-001 <br /> 622/04 <br />