Laserfiche WebLink
� � 1 <br /> �1 San Joaquin County <br /> r Environmental Health Department SITE <br /> j 304 East Weber Avenue, 3rd Floor,Stockton,CA 95202' <br /> 'tYl iiibATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> FOR Well Permit Application 04 NOV 12 PM 4* 4-3 <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 /> Assessor. <br /> WELL Location I60ITL(AR� Cross Street Ity� ip9� oParceI# <br /> lloS hyO' 13 <br /> PROPOwns, nn eil, -1O (O X017 <br /> Owner Address T.�, S(0 / n City (-10/r` (Z�ipPhone# 7 <br /> C-67 Contractor mt`w.l AddresstMkS (n;k U+`u14W`CityX16, �LidF�?a��Phone#,�ib'/—d 3/—�73�5z73 <br /> Consultant/Sub CntrAr Css E Address 3 JY�W City�Lic##hone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDRM ND fF R`) ]]DESTRUCTION (choose type below) <br /> Q SOIL BORING# �� OVER-BORE. DIAMETER <br /> �WELL# .3 ii a 0 PRESSURE GROUT <br /> Q`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL `IINNSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ��//1 <br /> ONITORING HWOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEfL WELL CASING DIA:g(,_ <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: a STEEL/ .PVC a OTHER: <br /> 0 VAPOR a MU-. ROTARY DEPTH OF GROUT SEAL IO TREMIE TYPE TO BE USED: ,<UGERS a HOSE <br /> B AIR SPARGE/OZONE a PUoii POINT(GP or CPT)GROUT SEAL PUMPED: O YY(�1e�s o (NOTE:MAXI_MUM.fREE-FALL DEPTH IS 301) <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS�(Z[ 4, 10� �]Yff I <br /> p OTHER:_0 OTHER APPROX.BORING DEPTH 3DY k!j5 —VOLTEItTRAFFIC 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 O ances, Rules and Regulati s,and all applicable California Stat ^ �� <br /> Signed Tille/Company I 712a�041,Print Name ahh $Q,X4 .Y-, Date 1t I3 Oy <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 16 0 1 Tor r n o k( o 4 <br /> WORK PLAN DATED: AU Q U S t 24, 20 W <br /> l I� <br /> Application Accepted By c [�� A � T Date Issued N 12 1 Z o 0 4 Area 1,4 5 9 <br /> Grout Inspection By o ///ZDate //-?2-0 Final Inspection B Date -0 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: Of -hkree Qravn <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3501 e,?-oo 99. 00 sR# Oo4o3� 1 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 622/04 <br />