Laserfiche WebLink
1%,,.6an Joaquin County <br /> 'a Environmental Health Depart>itygf;����SE4 SITE <br /> r V <br /> �. < 600 E.Main Street,Stockton,CA 95202-3 91 ITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/e�d ,� 0 2010 UNIT IV <br /> c P Well Permit Application VINt}iVi�AEPl7 F1r�y' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAT MITISERVICES <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work descri ed. This application is made incompliance with San <br /> Joaquin County eveel1opmenl Title,Chapter 31115.3 and the Stan ds of San Joaquin CJGG Envu��mal Health Department. <br /> Assessors <br /> Gnb o'fh+/f •an Gr Ty rrrceT r,�Mr 0=; 3 ` ` �-f C <br /> WELL Location 2�tgq y✓c!�</T// Cross Street /t' Gr City/JToc f Zip 4KU6 Parcel# 163 3 Orb <br /> PROPERTY � / �J/r CltySrpcj<Ttn Zip g�(Phone# 37-91Nl <br /> Owner �if tyof Stcc�rifAdress 23.00 #--1C <br /> I t' 1 <br /> C-57 Contractor F S't-h L 1n��/eC^ �/d ress 3°�L�She/� C,iitty lO. /<' 95L'lZLic# Phone#. 76A_q� <br /> Consultant/Sub Cnh CLtndCrrGY�^p/r`�re�+ddressAg W�QyS' �C,ry� �tic# !' Phone <br /> GIS Coordinates:X 63432-1 .5Ry 2 t 618 tl 1•X15 ,Townships Range f� Section_/ 6 ,_ <br /> fLG 4TT,ckeG(� '- <br /> WORK TO BE PER <br /> D NEW WELL . (CP GEOPROBE YDROPUNCH,HAND-AUGER,OTHER-) D DESTRUCTION (choose type below) <br /> D SOIL BORING# D OVER-BORE. DIAMETER <br /> — <br /> a <br /> WELL# D PRESSURE GROUT <br /> ArOther7a/ 9lCrnn 1.ti.1-11� :5-01�/,n^�''°g !r 14 In4r/Ms GROUT SPECIFICATIONS <br /> COMMENTS: aT / S a d -IQ 4'ta'f {'JGIPV✓ fin- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLES D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC BOTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL LS-`M� ('/S ti!TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE/OZONE OPUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUMFREE-FALLL DEPTH IS 30') <br /> 0SOIL BORING 0HAND AUGER GROUT SPECIFICATIONS lJtr►�Q+iMow4 t'�^'�~ <br /> D OTHER: D OTHER APPROX.BORING DEPTH t!C �'t'+fti D BOLTED TRAFFIC BOX or D 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 I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Re ulations, and all applicable California State Laws. <br /> Signed x Title/Company a("2 G <br /> Print Name <br /> Date lfi <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: Q <br /> Application Accepted By Date Issued S ' / Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> zqa PR-a' a`j•pD tilos i/ t° SR#S <br /> C-57_jZ WC , -WAIVER_ C-57 Letter of Authorization to sign permit�Encroachment doc_ <br /> 1 <br /> EHD 29-02-001web J <br /> 6/22/04 IJ <br />