Laserfiche WebLink
an Joaquin County • 1E ME <br /> E <br /> r� Envismental H6alth Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> • J��Q9)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application <br /> [008 <br /> t�ON•REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ON <br /> I� <br /> Applicstic*iiwo`'4`e� I�t��(y oaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin Cou��[�J�'y�ImE4U Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> u /�,� �// p )1 ')_ k 1 �T -? Assessors0 2NOZ.Z <br /> WELL Location �� (00 ��e '�r.- At- Cross Street(LD�'A IJP City 171r tD�'1 Zip Parcel# I Z <br /> PROPEL o (r� <br /> Owner �7Dhc t6�r'- YY��• �� JCC;�S Address(034' i 2oi'k. d Dr City'; cc `� Zipy524'7 Phone# 11-7i�"- `�� <br /> C-57 Contractor W V` Address9s�u !ug City7i=''O� ip9S�f SLic#2r)Z4hone#10_6&; -'-Z$Gr/ <br /> Consultant/Sub Cntr Address IO4(,/ 0/d P�<r�r��/�z eiRpCity"—4) Lic# P(2 6 S6/ Phone#q16 36'2-710U <br /> GIS Coordinates:X 3S.000 ,Y-121. 5 )P ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORT G# O OVER-BORE. DIAMETER <br /> I WELL# ��7 /4 20( y VEu7(6, /9 Ly a PRESSURE GROUT <br /> 0 •Other GROUT SPECIFICATIONS <br /> COMMENTS: — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE 'd" 0 MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS;Z /e k0 TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL &f�- 0. TREMIE TYPE TO BE USED: XAUGERS 0 HOSE <br /> IR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: XYes P No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ` i� nn''+3' <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 7'S Yh. XBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED N'i7 (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 I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rut s and R gulations, and all applicable California State Laws.. <br /> Signed x �'��• 71 Z Title/Company �65/y5 / ? <br /> 0 <br /> Print Name �rr'-G 5'/�f"f�� �7////� Date 3/7�� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: >O *2- . CVXW A-E,3 <br /> WORK PLAN DATED: 2 -12^�9 V <br /> Application Accepted By i�lDate Issued 3-20-6k Area <br /> Grout Inspection By Dale Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> NO I /H � /o 3•I) SR# DS3�5�' <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />