Laserfiche WebLink
-V'An Joaquin County <br /> - Envira�nental Healtr�Departm SITE <br /> Copy <br /> 304 East Weber Avenue, 3rd Floor;Stockton, e° 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 DAT <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This a .plicat�0l41ndcle in compliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Envjr Rrpeooli7 i + nt. <br /> WELL Location »$��{ }� 44 nP� METIAssessors <br /> u7„ Z ,"Cross Street 5sc cj� it. City1 o�c�e fel WT [ Parcel# 405-630&5- <br /> PROPERTY d4& <br /> Owner���rli2 �cc i�S��rrAddrw <br /> � Z �i " <br /> moi 1 City. 'L ai „ Zip SZY2- Phon'e#_ g -- ;6�S <br /> C-57 Contractor 4kLll ✓, - Address °y oak A,* , <br /> City' � e Zip3 Lic#G72Gl7 phone# o yt, <br /> Consultant/Sub Cntr A&EAddress S Cif <br /> Y �1 Lic# �ZZ Phone <br /> # <br /> GIS Coordinates:X Y Township Range `` Section <br /> WORK TO BE PERFORMED <br /> ff NEW WELL I BORING (CPT;GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER) <br /> p s�11L BORING# []DESTRUCTION (choose type below) <br /> LL# � s r 0 OVERBORE. DIAMETER <br /> RINEIl`Other_ a 0 PRESSURE GROUT:_. <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> RfAONITORING "-IOLLOW,STEM DIA. OF BOREHOLE �� <br /> �EXTRACTION ._..�. ©MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2 . <br /> AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:. []STEEL -.eVC 0 OTHER: <br /> D VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL_3r TREMIE=TYPE TO BE USED: <br /> UGERS 0 HOSE , <br /> 0 AIR SPARGE/OZONE' 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: gles j]No (NOTE: MAXIMUM-FREE-FALL DEPTH IS 30) <br /> U SOIL BORING o HAND AUGER GROUT SPECIFICATIONS .L <br /> Q,OTHER: g OTHER APPROX.BORIN11 G DEPTH. 25'Le,n' LTED TRAFFIC BOX or OSTOVEPIPE <br /> CONDUCTOR CASING PROPOSED IQ COMMENTS: (if YES, list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS.. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that I'have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, les and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company.4b <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /38e-9 <br /> WORK PLAN DATED: �`a-►� r / 2-20 <br /> Application Accepted By Date Issued +C� v <br /> _ Area <br /> Grout Inspection By Date Final Inspection 8 Date <br /> Destruction Inspection By Dat <br /> COMMENTS 1 CONDITIONS: 710, <br /> ACCOUNTING ONLY: AID# „F. _ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE t PERMIT I SERVICE REQUEST# INVOICE <br /> 350 g•� 2,392 � t, . -I�� SR# © �P <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 /> i <br />