Laserfiche WebLink
.i, <br /> an Joaquin Coanty, '°^ <br /> U-mn- <br /> Envir� me'ntal-HeAlth -Departmentt'd - SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> MITIGATION <br /> r (209)468-3449 Fax: (209)468-3433 Web: www.sjgov,org/ehd <br /> UNIT W <br /> Well Permit Application 2006 MSA -2. Am ti: 63 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE b§§VjEpt� ,,Q u iR, COUP <br /> � Y <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work de <br /> kI nrnade in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Envi t�2fif9tk11i r r�ePA7 <br /> WELL Location g a2C►I Assessors 1 <br /> u Cross Street M09 SE City L01\ Zip. 't0 Parcel#a$ gk O 1 d <br /> PROPERTY .I t <br /> Owner + { `�`rt <br /> actc�r-� Address_LL3_`1!�i1�op_rl '? Nw�City—L=b�.Zlp Z40 Phone#:_ZOO �3:� (nb i <br /> C-57 Contractor f ODD W 4A-Z) bC,t.tcA(Address <br /> City e 1I1� Zip rt `7J Lic# 7 t)0 Phone#_'�d� `{ <br /> Consultant/Sub Cntr a;,+ S � Address i o o ls,t iT)t^ R�+C Ci o�2�avA <br /> f .,Lic# Phone# 6 Yl1 d 123 <br /> GIS Coordinates:X 33a(a,�(� Y 2tZ6i . 74 � <br /> _ Township Range Section <br /> WORK TO BE PERFORMED: <br /> gNEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,'HAND-AUGER,OTHER*) . .0"DESTRUCTION (choose type below) <br /> Q SOIL BORING# <br /> Q'WELL# u�W- J 7 iJ y 0 OVER BORE. DIAMETER <br /> 0 PRESSURE GROUT <br /> O'Other "" s GROUT SPECIFICATIONS <br /> COMMENTS: <br /> §c <br /> ' ; <br /> TYPE OF WELL INSTALLATION TYPE Y CONSTRUCTION SPECIFICATIONS { <br /> 0 MONITORINGWOL LOW STEM DIA.OF BOREHOLE !)q-cff]MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_3 CotiC <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN, CASING THICKNESS TYPE OF CASING: 0 STEEL ff PVC 0 OTHER: " <br /> t2 APOR 0 MUD ROTARY DEPTH OF GROUT SEAL "7� TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: GrYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER a GROUT SPECIFICATIONS <br /> Q OTHER: 0 OTHER APPROX.BORING DEPTH (d b _ g 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 Regulations,and all applicable California State Laws. <br /> Signed x_ )OF&I)7',r/YZ"/,Title/Company r s� �y <br /> Print Name W r " <br /> d , ( f r f" "t, ,, Date oG�a2�`6 C. <br /> ,;i DEPARTMENT USE ONLY <br /> 9 r <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> 'WORK PLAN DATED: <br /> Application'Accepted By Date Issued 3 v Are <br /> Grout Inspection By Date I -O Final Inspection B "� ate 3•ik(-OI• <br /> Destruction Inspection By Date <br /> COMMENTS l CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# z <br /> PE CODES FEE INFO AMOUNT REMITTED , CHECK#+ RECD BY 'DATE "" " PERMIT/SERVICE REQUEST#° 'INVOICE <br /> d2542-q . SR# 02,7- <br /> C-57 <br /> ZC-57 WC -WAIVER C-57 Letter of.Authorization to sign permitAEncroachment doc! <br /> EHD 29-02-001 <br /> &22104 <br />