Laserfiche WebLink
San Joaquin County <br /> oZ Environmental Health Department SITE <br /> '{ 304 East Weber Avenue,3rd Floor,Stockton, CA 95202 <br /> MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: j ov.org/ehd UNIT IV <br /> WN I OV -3 PM 2: 07 <br /> Well Permit Application <br /> JJ, <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FR Ttr',I S+l1�EfJ` C()Un T y <br /> n v rN �� p <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install ttFiiwArk�'�4c�f n cation is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmf enfJI 1%fartmernt. a f <br /> 3q�5 JD 0� 1 q firw►61V_ 1�►Du-V �l. f:��71 J JAssessors i� ISI 1-03 <br /> WELL Location U CC Cross Street C�aY� City Irv^ -zip Q P(a�rce(ll# �j <br /> PROPERU'a � b Addresses+6J '"IV�S Cit y0 ►V Zip"�./� Phone# l Zf ` �" <br /> Owner JJ Qyyl���q t1.�f AAI stn `6 (/� Q r (y� ,t <br /> C-57 Contractor!'4 i A��I,,,w►,I�1p1t/h�C1 Addresst7��U V "p�1�%f ' '� c city c��r"f'r Zip`7�6� Lic#� 2&17Phone#��� M1������� <br /> Consultant/Sub Cntr/rtt�vkA�Cl1l law ytNN Address 0✓1 Ekaw9_O` City3l C M Lic#630,2�Phone#20"��I"jU <br /> GIS Coordinates:X Y Township Range Section �a <br /> WORK TO BE PERFORMED: <br /> '' NEW WELL/BORINGT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) p DESTRUCTION (choose type below) <br /> a SOIL BORING# � o OVER-BORE. DIAMETER <br /> -JJCWELL# $ 7.% 0 <br /> 6 a PRESSURE GROUT <br /> 11'Other GROUT SPECIFICATIONS <br /> COMMENTS: y&W-1 = JS S ' Td -7-6 ` SrA"v. heou 'CRn tip G- oy-4' 0 fa&O-s- <br /> TYPE <br /> {TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS l� <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL PVC a OTHER: <br /> o VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 50-&6' TREMIE TYPE TO BE USED: *AUGERS D HOSE <br /> a AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'ASOIL BORING O HAND AUGER GROUT SPECIFICATIONS Food AND CEAN")r <br /> a OTHER: [)OTHER APPROX.BORING DEPTH Q Sao 0� a BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> //' pp� � CONDUCTOR CASING PRQPOSED N (if YES,list specifications in comment section) G <br /> COMMENTS: lk S4t( tctyJ tdhpl�Gtl:.Q , Ividygkffi " nii-MOVU6�t j UgjLf �lb Wow &W d2okv, <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. v <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> L <br /> hereby certify th I have prepared this a lication and that the work will be done in accordance with San Joaquin ' <br /> County O 'na e , Ru n egul s, and all applicable California State Laws. L t f _S <br /> Signed x ,-�11 Title/Company m�(�4X &-eo�Vnvx 'G�` t(AL <br /> Print Name ! CY�i'Ir V L 1� Date 10 3 05 ••^^_(( <br /> DEPARTMENT USE ONLY ! <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3 q '� Ff S Hwy 7 S <br /> WORK PLAN DATED: I b I SID Sr <br /> Application Accepted By ..-. Date Issued'O S Area Zri <br /> Grout Inspection By <br /> 1i(,, nnnc^�,� Date I I z Final Inspection By Date 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 /> sr►.do36�, G� tt �g fob SR# �.Zg <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 />