Laserfiche WebLink
„an Joaquin County HECC111�3 v E <br /> *PO <br /> Environmental Health Department APR - 9 2010 SITE <br /> 600 E.Main Street, Stockton,CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web: www.sjgov6N WMSERVICALH UNITIV <br /> Well Permit Application <br /> ES <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 /> z 5 00 N JOY ; n Assessors <br /> WELL Location A✓�/ ✓PLross Street 11 ���� ��•'�3CIly Srp��reit Zip -156 Parcel# 162I100I <br /> PROPERTY /I.1NAil� aI Uri A 5 efr I <br /> PROPERTY <br /> 1 sto Address 54 le �r spa�G City Zip Phane#��209937 873y <br /> C-57Contraclor Pr.--c y;f`n5sr�rl.ngtddress Z36-5!T m ��e.CityZip 5W-5-jc#�����+•��Phone# Z09 W5'�7I2 <br /> Consultant/Sub Cntr Con a[ar&r r0ee� Address 189 �/'an L l✓sif�f, city Sr tr r Lic# Phone# 209 Z j 4-OSI f? <br /> GIS Coordinates:X &319 121 .Q 1 .Y 2-I OQ 49 ,Township Range__& Section <br /> WORK TO BE PERFORMED: <br /> ,NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION (choose t ejelow) <br /> p SOIL BORING# OVER-BORE. DIAMETER N c rA6.--t <br /> k*ELL# wlA t Mr'to$ 0 PRESSURE GROUT <br /> '11*Other GROUT SPECIFICATIONS <br /> COMMENTS: V� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> A ONITORlNG ,a'HOLLOW STEM DIA.OF BOREHOLE O 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sek tfOT w`OF CASING: 0 STEEL , PVC 0 OTHER: <br /> 0 VAPOR O MUD ROTARY DEPTH OF GROUT SEALZZ gTREMIE TYPE TO 8E USED: �^°UGERS 0 HOSE <br /> U AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes�y 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') Tx <br /> I� <br /> pSOIL BORING pHAND AUGER GROUT SPECIFICATIONS "1 Ib fO pi tA�tA�LCwwV� <br /> 0 OTHER: Q OTHER APPROX.BORING DEPTH 11 W YL*61%a 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 I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulati ns and all applicable California State Laws. <br /> Signed x /' t TitWCompany O <br /> Print Name—31, G a O Date 3 3010 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 7_5” 10amort Ib rAA^ <br /> WORK PLAN DATED: Z�yt I Kt <br /> Application Accepted By .1/r• Date Issued Area <br /> Grout Inspection By DateE1(4Z�Final Inspection By Date 4'r-1 <br /> Destruction Inspection By ^, Date (.8� <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 /> -Ap'�- m-9", Sal-° J i1141t- SR# 5-at--:-44 <br /> C-571Z— WC=WAIVER_ C-57 Letter of Authorization to sign permit4,--E-ncroachment doc_ <br /> EHD 29-02-001web <br /> 6/22104 <br />