Laserfiche WebLink
! ISan Joaquin County <br /> Environmental Health Department SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 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 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 /> C"6VeR- e- Mlle^J . ' -1�$�V %R*+Y_7' 9 37 Assessors $-3 03 D/ <br /> WELL Location _Cross Street City -Zip?_9377 Parcel# <br /> O F1 f� <br /> PROPERTY <br /> }} ✓ C0lVW1yd /1AEC%0A/ ifyONone# 'pJ <br /> � �� <br /> �"�t1L/.O ✓if/ O A?�Ri/i✓,C� 9f�.S.S�S �f.S/`s 9� 5���"' ���117 <br /> C-57 Contractor <br /> ITO�/C��jAddressg� f/N✓� /l�A City Zip Lic# Phone <br /> Consultant/9trtrCPftf Sof/!✓ Address ��! CC�i �~v�Lic# Phone<-'? '2 <br /> GIS Coordinates:X 'Y ••,Township 3 -� Range S Section <br /> WORK TO BE PERFOR 0- N/ <br /> l CPT,GEOp}206E,HYD NCH HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL # /`� OVER-BORE. DIAMETER <br /> ®WELL# Q PRESSURE GROUT <br /> ®*Other GROUT SPECIFICATIONS p- <br /> COMMENTS-._ / � �y/�8!j✓ii+r 7� c�G✓ �4 eleWlf c74 <br /> ,S r�/��./�rot,�-�c�a✓o�'�"' do�+�p .J <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING HOLLOW STEM DIA.OF BOREHOLE o MULTIPLE CASINGS o MULTI-LEVEL WELL CASING DIA:—!I�! <br /> a EXTRACTION ®'AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: o STEEL ®PVC a OTHER: <br /> ®VAPOR ®MUD ROTARY DEPTH OF GROUT SEAL '75 /r-7 TREMIE TYPE TO BE USED: Q AUGERS o HOS <br /> ®AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED:Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> OIL BORING ®HAND AUGER GROUT SPECIFICATIONS M£!/Pf CEw ,Y, <br /> ®OTHER:_0 OTHER APPROX.BORING DEPTH F7`0 B LTED TRAFFIC BOX or Q STOVE PIPE <br /> L J CONDUCTOR ASING PROPOSED 6® (if Y S,list specifications in comment section <br /> COMMENTS: �C��a�a✓' TSU✓/i2/ 7� SP 1G0/ G✓�I? C�GYYIC DI CT f� O✓C /--AE'/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 and Regulatio d all applicable California State Laws. <br /> Signed x-_s��'.�� ,s'��✓/OJC' E/✓//N�E/E' —P<✓A 1'dZ/!� G�1?%�' <br /> i TitlelCompan <br /> ',f�l}?l� y 9 <br /> w` / /9�E� Cire/e�1ZG Datec� /✓! / <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED:/ �c <br /> Application Accepted By "� ��P � sem! /�° Date Issued ,,/f///,g 1 Area <br /> Grout Inspection By �Qye Date1112-91407 Final Inspection By nr' t � ! ate 42//40L07 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: fAa <br /> D &6/0r—i <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />