Laserfiche WebLink
.. �quo <br /> 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:www.sjgov.org/ehd UNIT IV <br /> IV 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 /> WELLLoeation I6T_ Souter w:\"d LJm4 Cross Street Marke} Sl. City5}Vck -Or Zip Parcel# <br /> PROPERTY <br /> ownerM*V\a . 94 Asvtinr Address (061 wade- Avc-- City/A04e%+6 Zipg 5351 Phone# <br /> C-67 Contractor V S.W Drill.I! Addre,, 100 ityZSeL4u., 7ip°IS(04 Lic#7201 04 Phone# 9(6--l»' `1/00 <br /> Consultant/SubCntr lrrovAj -r.ero A+alvj dress V1 AAA;. S}• City I Lick Phone# ?a9-X38-gfi84' <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 'fNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> WELL# M1.1 11 C- 0 PRESSURE GROUT <br /> a Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> v <br /> MONITORING a HOLLOW STEM DIA.OF BOREHOLE IZ/9'I ULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2 <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS stk. '{O TYPE OF CASING: �TEEL ;PVC BOTHER: <br /> 0 VAPOR AMUD ROTARY DEPTH OF GROUT SEAL 1 0 (o TREMIE TYP TO BE USED: E AUGERS NOSE <br /> u AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: A Yes ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> BSOIL BORING BHAND AUGER GROUT SPECIFICATIONS Neal- Cg-A.^4- Aro,,} kry. s-IF-se •., (0(9 Fre f 67�- <br /> OTHER: ()OTHER APPROX.BORING DEPTH lT-o ' BOLTED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED .I 2 S (if VES,list specifications in comment section) <br /> COMMENTS: bt�g j1 d:u..+-k' tw.due lar CcK%-a WAk lot in�hallt� {cg olp,P'('h df QD Feef- <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 Regulation all applicable California State Laws. n <br /> Sign ad 000Title/Company StAF� {/ Qtl10 r��f'I- /bra..ntJ 2B'a ry,..ulyf •S <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: './DeGe6ft6cs7G0S <br /> Application Accepted By '41e h,// Date Issued f�AP4 zag'-r Area /.`r3 <br /> Grout Inspection By Date Final Inspection By fjy Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC* <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 'k 9 , i 339Ny- <br /> 3Jr s,usr 3'2x9 .•-. /66z? / t)X SR# Ooq( {01 <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 />