Laserfiche WebLink
San Joaquin County, <br /> Environmental Health Department��U�l�y SITE <br /> j < 304 East Weber Avenue,3rd Floor Stockton,CA 9520S"^* ' yf <'GMIQATION <br /> r Jj <br /> IF <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/eldf�� rfI V <br /> ORS Well Permit Application C,c� ,j� ,�`y �y 15, - <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 Assessors <br /> WELLLocation 2111°11j Loam 5 0.d CrossStreet qq City 5�0c4-l-0r, Zip`lSZ5Z Parcel#-179- (( OZ4 <br /> PROPERTY 707'4 Las-bo lS <br /> Owner Marr�-'�' 1�10.YG, Address <br /> 20 Jao1o�\�l[y.r� City ��_Zipg553) Phone# <br /> \ttu Address P.V- �t%7e C\-7�_City, !_ccl I Zip5,5211 Lic#�ZVJD4Phone#_(Z0�3(,rI C{(P� <br /> C-57 Contractor � �rV 11unr� <br /> t/Sub Cntr!'epjg 3jtaj—%6jq CS Address 00 , �� C� ' z=L� Phone#L21Y� <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p,NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0I DEER RUCTION <br /> RE. DIAMETER(choose type below) <br /> SOIL BORING# EW 101 -1-0 EW ID3 i 0 PRESSURE GROUT <br /> SWELL# S W- I SMI- O1� E i�J I '� qvj?)" GROUT SPECIFICATIONS <br /> Q*Other f A5- 1 <br /> t: C+-4iaeV�ed lrJork � c'a-� q <br /> COMMENTS: SeP <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> U MONITORING a HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: <br /> .EXTRACTION L(P) a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 11 PVC O OTHER: <br /> a VAPOR o MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> $AIR SPARGE/OZONEQh PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING p HAND AUGER GROUT SPECIFICATIONS BOLTED TRAFFIC BOX or p STOVE PIPE <br /> LZ <br /> AOTHER: �J p OTHER APPROX.BORING DEPTH <br /> CONDUCTOR CASING PROPOSED (,f YES,list specifications in comment section) <br /> tirt�LG}Lpr\ ��15 <br /> wee a a�e�l U9 oy-K- ��� dQ Si'r`e a zoolfl <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 Or aces; Rul s d Regulations, and all applicable California State Laws. <br /> � "- Title/Company <br /> Signed x -11 <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2 9 6 9 Lo <br /> WORK PLAN DATED:�/ u 0 0 <br /> Application Accepted By �a r r7 Date Issued J u n e, 1 S 2007 Area ) <br /> Vt o Y L. M <br /> Grout Inspection By �j:r <br /> �. r:.- r Yla�.a f � Date 17�L 1 Final Inspection By res 1� � Date l' L Z -U 7 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> WACCOUNTINGONLY: ID# FAC#MOUNT REMITTED CHECK# REC'D BY DATEPERMIT/SERVICE REQUEST# INVOICE <br /> 37 .4. Ov a/9S'2'7 <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 />