Laserfiche WebLink
ORIGINAL <br />San Joaquin County <br />nD <br />x'. Environmental Health Departmental ECE�� SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202` <br />` MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sj-ov.org/e Q $ 2004 <br />UNIT IV <br />Well Permit Application ENVIRONMENT NE <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS SUEDERMIT/SERVICES <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 />WELL Location (� ross Streetq Assessors <br />City Zip l 5 Parcel# <br />PROPERTY ,L„_ _ <br />Owner C tI b 0 (10M Address 3()t5 N IF <br />ad 6 ccy <br />C-57 Contractor 25i__+ Address ,z OIli. F <br />T Cit w <br />Consultant / Sub Cntr 11r'(/Ite4111v I j -+ ROLW , .11j.gc I /��..J r, -4 <br />4 <br />GIS Coordinates: <br />Township <br />� <br />WORK TO BE PERFORMED - <br />0 NEW WELL /BORING CPpR <br />, HYDROP N H, HAND -AUGER, OTHER*) <br />SOIL BORING # My -,q)5 - J � t <br />WELL # 6 <br />0 *Other_ <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 71 <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE <br />__3_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS <br />0 VAPOR TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 MUD ROTARY DEPTH OF GROUT SEAL- §--G L TREMIE TYPE TO BE USED: <br />0 AIR SPARGE/ OZONE l'�(PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 AUGERS 0 HOSE <br />`%SOIL BORING Tv 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />// 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH �� <br />0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />COMMENTS: CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACH <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. ENCROACHMENT HERMITS. <br />I hereby certify that I have pre ared this application and that the work will be done in accordance with San Joaquin <br />County Ordinanc , Ryr1`es d R ulations, and all applicable California State Laws. <br />Signed x (/ J <br />go(� <br />Title/Company <br />Print Name <br />Hata <br />Ra <br />Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />P(PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 130 No y-+Jl 141, esS}y-ee-- <br />WORK PLAN DATED: Deccmb r !D Za <br />Application Accepted By_\1iC' "I !) /' i Q M�, Date Issued �►/ p� 0 <br />�r /A- 4e --r /3 20rea—�� <br />Grout Inspection By Y i hM 1 In A �(,.,,, __ Date_ Z yQ_p t f Final Inspection By ' <br />Destruction Inspection By �"��— Date__17. — Z4 <br />Date <br />COMMENTS / CONDITIONS: /i ✓n w a _ -2 1 <br />J s <br />[ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO EAMOUENTMITTEEE REC'D BY DATE PERMIT / SERVICE UEST # INVOICE <br />iso 89. o ( sR# D04 OGL 0 <br />C-57_ WC --WAIVER _ C-57 Letter of Authorization to sign permit_ Encroac me <br />F1 ID 29-02-001 <br />6/22/04 <br />