Laserfiche WebLink
ur <br /> San Joaquin County <br /> Environmental Health Department <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 E <br /> (209}468-3449 Fax: 1 <br /> t;Po' eta (209)468-3433 Web: www.sjg0v.org/chd 6 %1GATION <br /> Well Permit Application E VIRAMEIY NIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATfE fSSUED <br /> Appfication is hereby made to San Joaqufn County for a permit to construct and/or install the work described. This applicationr1SECES <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> CbVNrY CpV PTtj0V 5 thDat is made in compliance with San <br /> WELL Location '�2.Z W E A V�N U I= <br /> Cross Street SAN TOAQVINCity S O4TON Assessors <br /> PROPERTY SAH TOAQVIN COVNty RGEr zjp 9S-L04 Parcei# a <br /> Owner C LITIE Address 1 22 E,SG01T5 <br /> Avt , <br /> C-57 Contractor City $T6F_'" 4- 5-2QS Phone# zo9 6 - <br /> I; G IJ R I L 4 I F Address 150 <br /> D ; <br /> CityMARTti�zip 2q53 53 Lig#6 S 6 X10}Phone# 9i <br /> Conons_ultantt/Sub Cntr 'RAMAC:-E tI`jV IN -Address 46S5' ME4DOW$ PkwY� Svit�20PI�alS "5$flt) <br /> GIS Coordinates:X 'Y City----Lic# 5 S Phone# 'T}5 $SI-jZ 39 <br /> ,Township <br /> WORK TO BE PERFORMED: Range Section <br /> j NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION <br /> I SOIL BORING# (choose type below) <br /> 0 WELL# FILE <br /> COPY <br /> 0 OVERBORE. DIAMETER <br /> 'Other 0 PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION PECIFIC TIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2 n <br /> 0 MULTIPLE CASINGS 0 MULTE-LEVEL WELL CASING DIA: NA__ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS N A TYPE OF CASING: a STEEL <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL NA TREMIE TYPE TO BE USE PVC 0 OTHER: <br /> USED: 0 AUGERS HOSE <br /> 0 AIR SPARGE/OZONE A PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 1 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS N LAt CEMENT' <br /> 0 OTHER:_________o OTHER APPROX.BORING DEPTH t}of n BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED No (if YES,list specifications in comment section) <br /> COMMENTS: RAM Cri: thy, Pt�vj&EV X40AK PLAN ( S 1 106) <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 Ordi ces, Rules and Regulations,and all applicable California State Laws. <br /> Signed x_ Title/Company PRESIDE [�AMIkGfr ENyIRON t L INC <br /> Print Name SOS p P,A M&G E Date I b 1(3 b ` _ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 22Z sia A V <br /> WORK PLAN DATED: A u y,5 1 4 2,0ep <br /> Application Accepted B �� � &�1 Date Issued [� _�-d b .r 7, Z0 o (,.,_Area 1459' <br /> Grout Inspection By Date 111jC07 Final Inspection Byy)iia{G �. G�iYate <br /> Destruction Inspection By 0 Da fe <br /> A <br /> COMMENTS/CONDITIONS: -I•f PT <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 35,01 s 374 <br /> sR# 0a4 $5-6,S <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 />