Laserfiche WebLink
��,cq�'•^!. co .jan Joaquin County <br /> �,. <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application <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 /> Assessors <br /> WELL Location Z l o g•SAG6e,Q-Ml t&J777 ST. Cross Street wA4WCf7-S% City L-"/ ZipYSz O Parcel#-04f3-0`fg r0 <br /> PROPERTY <br /> Owner 7 Vft 5 fAGK50tiI Address Z(0 S, 5',4-CgAol6Fru STCity LOQ( Zip Phone# <br /> C-57 Contractor V/ 'W 02/G.C.//✓(,r- Address P0.6,DX-'f (v City1$4F7`PAJ Zip1r6,'( Lic#7z0'I0Phone#969- ,?-NfS- <br /> CILvO. <br /> Consultant/Sub Cntr E4IZ7'H N.9r6AI S Addressg7$S3 olA+fM Sffl;J(r5SCity 6;410rLic# Phone#570'-3T3-032.0 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> gni EW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> OIL BORING# L [ !> GA-c/Y 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM OK DIA.OF BOREHOLEn � 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> [1 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC []OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: gCTHER FL!4,Nr',4U41V APPROX.BORING DEPTH /571 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: (404-E5 w t l c- /V&—1 /3E 4-9FT op5:;Aj <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 Title/Company F4k7-F� SYSTf 7�(/S GO�SGILT/ S <br /> Print Name l3/2S/A7�1 ll�N S Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATE[D]: p <br /> Application Accepted By g lllT'"� Date Issued 3r2 l Ip(, Area 9 G <br /> Grout Inspection By Date 016 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: CSA 01 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> z-'.D( �� - 110-3 � 3/z,/o( SR#,o-p &120 <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />