Laserfiche WebLink
U San Joaquin County <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: v. /ehd <br /> Well Permit AMPa on OUKT y Ffurwfty <br /> Off. <br /> NON-REFUNDABLE PERMIT EXPI ,,%i kl r , tSWED <br /> Application is hereby made to San Joaquin County for a permit to constructr� (2)II[peeRv scribed. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of oaqum County Environmental Health Department. <br /> essors <br /> WELL Location 230WET SLA•JE Cross Street IgLMNC� <br /> iOCity 4`1b 1470N Zip gQO2 Par <br /> 7- cel# 117,05-0 3 7 <br /> PROPERTY <br /> Owner SAV 401MYN'-Ugd-WAddress 'A.O,ROX ?21i City�—�iCArb'_ZipT,S�o/Phone# Z Z. gT07 <br /> C-37 Contractor IeS 1 Address 2.20 lV. C-kS'r ST City6pq> {N PV? Lic# Phone#_$.3b C Zm( <br /> Consultant/Sub Cntr ?t. LtSsvg1.4MSAddress If GaN /aLM y_ Mt Dc# Phone# D S7 A.Jxl <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> WQRk TO BE PERFORMED: <br /> EW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> WIL 13ORING#_s/X &0R jjo _C a OVER-BORE. DIAMETER <br /> WELL# Q PRESSURE GROUT <br /> p*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Il MONITORING OLLOW STEM DIA.OF BOREHOLE,,(O'! a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASINGTHICKNESS A/4 TYPE OF CASING: 0 STEEL U PVC BOTHER: <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS a HOSE <br /> a AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: g Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> KOIL BORING p HAND AUGER GROUT SPECIFICATIONS C > o0-f' <br /> a OTHER:_n OTHER APPROX.BORING DEPTHS 0' <br /> a BOLTED TRAFFIC SOX or Il STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: SF C ATG L,JdYRK/LA.d allV-40s 417. Oft TES �.r. <br /> T— <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 apd R ulations, and all applicable California State Laws. <br /> Signed.14.. Title/Company P/LmFd+QdYa,—AL, <br /> Print Name dr�E� _ -___- Date �l0 - <br /> DEPARTMENT USE ,O'N/LY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 9302- Nodia V� e S f L Q ri e— <br /> WORK PLAN DATED`:, I� a Y'CI� 1 (e. 2-604, 1 <br /> Application Accepted By Y Date Issued Ol"I, t 2 6, 280 Areae <br /> Grout Inspection By Date S- .23 L Final Inspection By d ate $�-2�-OC <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> '35-01 3 .21q3 '0 SR# 0 4(P 51 Q <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 />