Laserfiche WebLink
. FILE COPY <br /> oPaU'k`°� San Joaquin County <br /> Environmental Health Department SITE <br /> (: 600 E. Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: wwxv.sjgov.org/ehd UNIT IV <br /> g��Fo Well Permit Application <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 an aquin my Environmental Health Department. <br /> I olk Assessor /�� �t <br /> WELL Location� � Cross Stree City ��ip Parcel# -ufs�'b8 <br /> PROPERTY <br /> Owner M/d C" O Address 2-4q& Y m6nimCity 14cri4eC4 Zipn37Phone# n <br /> C-57 Contractor J� �M Address PA �' Cit }&(1b �ic#�Phone##_*A&-4Wp-ffb9 <br /> 't� <br /> Consultant/Sub Cntr 5Address �w ��Itya Lic# Phone#5111-A4- / <br /> GIS Coordinates:X/ZI OL Y S/ yS Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,'NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> ]OIL BORING# +- S -A4$ M-A47 0 OVER-BORE. DIAMETER <br /> WELL# f —j ,PRESSURE GROUT <br /> 0"Other 5/2��*3 f2 /• GROUT SPECIFICATIONS <br /> COMMENTS: lz 5041 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 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 /> CeAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1 c.0 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONEpdPUSH POINT 0or CPT)GROUT SEAL PUMPED: 0 Yes a No (N TE: MAXIM <br /> � FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_U OTHER APPROX.BORING DEPTH S-'. 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> n,�, �p C DUCTOR WING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: 7 <br /> `�2P,0✓�/ll f �� - f <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 /> CountyITF— <br /> Rules Regulations,and all applicable California State Laws. <br /> Signed x Title/Company "IA l C <br /> Print Nam 1 P-3 o-I Date <br /> DEPARTMENT USE <br /> /ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: `( <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection B `u Me ��Z <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 /> RkW168'Z -2 SR 35 <br /> C-57 WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encrment doc_ <br /> EHD 29-02-001 web <br /> 6/22/04 _ `` <br />