Laserfiche WebLink
Mar. 14. 2008 1:59PM Nc. 2219 P. <br />n Joaquin County <br />Environmental Health Department <br />600 East Main Street. Stockton, CA 95202-3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web. www.sjgov.org/ebd <br />Well Permit Application <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <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 />WELL Location .2- -1 0, Riackr. iq Cross Street Al et vy City (51-PC4---Ofk Zlp 6152_4s Parcel# 16 Z.-- — <br />PROeFrERTY-- <br />crt C464:okAddres, 7-2-e)( 100,54 4 nCity cfeCk--1-514 zipc152-63 Phone# (-2-0 9) q (16- OZ!/ <br />C-57 Contractor (1.)D1"•'\ kv,\ Address City Zip LiclO2P(O ttPhone# q' 3'e - 16 <br />Consultant / Sub Cntr E. 0 Address ig C1C7 laitifertOt 3/C CitY 14)(1-1,1;t:gS, Lic# ?-ei Lfe 2-4) Phone* (/ / ?` 16 00 <br />GIS Coordinates: X <br /> <br /> Township Range <br /> <br />Section <br /> <br />WORK TO BE PERFORMED: <br />ANEW WELL / BORING ,--", GEC/PROBE, HYDROPUNCH, HAND-AUGER, OTHER) a DESTRUCTION (choose type below) <br />/1K,SOIL BORING # --7 a OVER-BORE, DIAMETER <br />U WELL # a PRESSURE GROUT <br />U Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 1:1 HOLLOW STEM DIA. OF BOREHOLE 2" 1:1 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: [I STEEL g PVC g OTHER: <br />U VAPOR Il MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED! g AUGERS 1:1 HOSE <br />0 AIR SPARGE/ OZONE )(PUSH POINT (GP or CPT)GROUT SEAL PUMPED: ['Yes a No (N.:31:3AAXIMUM FREE-FALL DEPTH IS 30') <br />ASOIL BORING a HAND AUGER GROUT SPECIFICATIONS Irk-ed.A- CI, , <br />O OTHER: a OTHER APPROX. BORING DEPTH 8 - -40 / a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <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, R s an Regulations, and all applicable California State Laws. <br />Signed x Title/Company <br />Print Nam 4 vA,e,--ip tA r ((A tt R- Date 3 5/ <br />DEPARTMENT USE ONLY <br />Cva 3A--6-1-0„ P.0146-t- e-k--0.141 IS SITE MAP IN UNIT IV FILE, ADDRESS: 2- 2-0 / <br />Date Issued '?/20 10 e. Area 7i7 <br />Date <br /> <br /> Flnal Inspection By <br />Date <br />4211L__ -11/ <br /> <br />AA-I ?kw, <br />ACCOUNTING ONLY <br /> volommigamisob <br />AID# FAc# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT /SERVICE REQUEST # INVOICE <br />_ ,5 ,r17-°d / b g ) ic-k—, 3/2_,fy6e, S R# e&C-3 6 C C <br />5/Kc <br />WORK PLJ5,14 DA,TED: 3Ir-ilDg <br />Application Accepted By <br />Grout Inspection By /4- <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date <br />-WAIVE P C-57 Letter of Authorization to sign permit Encroachment doc C-57 WC <br />EHD 29-02-001 WEB <br />9/11/2007