Laserfiche WebLink
oP ��E0 vD San Joa vin Count FILE COPY <br /> /. q Y <br /> ' z Environmental Health Department SITE <br /> O 2006 304 East Weber Avenue 3rd Floor Stockton, CA 95202 <br /> MITIGATION <br /> WENT HP115l"68-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> ,1HT/SERVICES <br /> 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 of San Joaquin County Environmental Health Department. <br /> /�L�/ ({DkSC_I�a.Ci Assessor i' <br /> WELL Location/1 K/ gross Streetez, City ({ U ip 5 fv Parcel#� -1:5 <br /> PROP E �,Q��� Ar <br /> �p t ,f�r[� �2 - �n�� <br /> Owner VOW ArIA Address-/11 L. 411M J I. City l%&t Zip 7(o Phone# Q��^ <br /> C-57 Contractor V(� AddressQ l kNECD tfxl7- CityPAC-114 a Zip ic# Phone# 7L�"52�-1y90 <br /> Consultant/Sub Cntr.<Ft liC Address//&j BWWWN,*AX City_0y4A#jD Lic# Phone#.5/6-y33-11635' <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> )KNEW WELL/BORING (CPT: EOPRPBE,_pYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> SOIL BORING# -` OVER-BORE. DIAMETER <br /> 0 WELL# SV�6 y'?i� a PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE !' 0 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 /> WAPOR a MUD ROTARY DEPTH OF GROUT SEAL 25' TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> D AIR SPARGE/OZONE APUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> XtTHER:ll O OTHER APPROX.BORING DEPTH 23*' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <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 have repared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinanc , Rul nd Regulations, and all applicable California State Law"ss.. <br /> Signedx Title/Company S'E�v1�2 7P-0)E� rJAlCK <br /> Print Name Date /Zg�D�a <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area D 7 <br /> Grout Inspection By to Final Inspection By &�Affiare A" to <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 411 l 0 7• 2 $ !/ 3 �K S <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Enc5rgetfiment doc_ <br /> EHD 29-02-001e� G�1 <br /> 6/22!04 <br />