Laserfiche WebLink
San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 9202 MITIGATION <br /> (209)468-3449 Fax: (209) 468-3433 Web: wwwsjgov.pfQl�d.N —J PM 2: NIT IV <br /> i LOODUT JJUU <br /> ?Jn Well Permit Application <br /> SAN JOrSUUIN COUNTY <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE IQN V IR tO N HENT A L <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work descriA5`�ii1 Wppfi&,AA IsTrI"Tcompliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. /b.3 32 Q O ?A," <br /> i�,� (,iLziL ) 7'/LUFr�'uyS Assessors > '•'W/ <br /> WELL Location�00 A 14 ,[ �_Cro s Street"�a F Ciry �'rocK'roJ Zip 9571.—Parcel <br /> 1 6.- 3064 U/g <br /> PROPERTY Phone#0209/937-57 <br /> Owner�T�OF 5-rII Address 75e0 A�A.u4 I�Iz.tu6 City S-roeLTD-) Zip <br /> C-57 Contractor I�}W •DrLWAY r /A1LAddress 1/6F/Ff/+ 51ga&-r CityISLETOA/ Zip751'1i_Lic# ,Phone#�9/()777-`//Q'D <br /> Consultant/Sub CntrC• •nor +�N� v wnaf5 Addressor G.ue.r✓r.k.e.C194L City:1111 r 61 Lic# Phone#(? )L3'/•051Sv <br /> 4tf r SNrre.L ) <br /> GIS Coordinates:X N 37' S6r 115,Y.�ii�lW- r 2At•".Township T /N Range.� Section <br /> WORK TO BE PERFORMED: <br /> `'oMEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION (choosetype below) <br /> I]SOIL BORING# 0 OVER-BORE. DIAMETER <br /> $'WELL# rA0PRESSURE GROUT <br /> [I-Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> `MONITORING HOLLOW STEM DIA.OF BOREHOLE In I 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> O EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5Q4,40 TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> 0 VAPOR O MUD ROTARY DEPTH OF GROUT SEAL ' 2-0 r TREMIE TYPE TO BE USED: D AUGERS AHOSE <br /> 0 AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes Po (NOTE: MAXIMUM FREE-FALL DEPTH I 30') <br /> 0 SOIL BORING 0HAND AUGER GROUT SPECIFICATIONS)v(L3E TJ71 AJEAT-C¢rNEA1T - 455/) AtAm.Aj/r <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH �' ZS! BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED A D (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 prepay d this application and that the work will be done in accordance with San Joaquin <br /> County Ordinaces, Rules a egulations, and all applicable California State Laws. <br /> Signed Title/Company �'yA'• y e1,�:2f��lltdL�s/�J /A.1_ <br /> Print Name Dates <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: (� /y` ,// 7;r�1`/ <br /> Application Accepted By t Date Issued J Wim- /700 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 FEE INFO AMOUNT REMITTED CHECK# REC'D BY pDATE PERMIT I SERVICE REQUEST# INVOICE <br /> z qq 2 7 4� 61/61 SR# q Z 0 <br /> C-57_ WC=WAIVER_ C-57 Letter of Author'izatia o sign permit_ Encroachment doc_ <br /> EHD 29-02-001 <br /> 682/04 <br />