Laserfiche WebLink
k1 San Joaquin Count ORIGINAL <br />9 Y <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 />Well Permit Application D <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 />IIAssessors <br />WELL Location 'Doy"t'D Jf. Cross Street �r�(tI, �� Wu City9,X-11-t-,1 Zip 75.20' Parcel# I •-09�0-/(a <br />PE CODES <br />PROPERTY A <br />Owner ���Oc o PL: lI !'�S Address_ 3I� u; lc:� it.p City b e eL0p 570606 Phone# '-VA <br />AMOUNT REMITTED <br />f <br />C-57 Contractor AL E- A2J;a-J"/�SAddress 9,590 �w�L ��innJJ�'��City —D'kZ_i/p`,. 6 Lic#z��26Phone# �`GZPZ-?$Z� <br />REC'D BY <br />Consultant/ Sub Cntr .' !P �nI . �7�r%e Address -304 /A ] QTe- Kct• City &q!!ut �d*ic# •/1t Phone# fit, -601-0''/DO <br />_ <br />a l <br />NV <br />GIS Coordinates: X 'Y -IJA —Township '✓A Range "�'� Section—l-VA <br />WORK TO BE PERFORMED: <br />C�'t <br />(;]'NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) [] DESTRUCTION (choose type below) <br />> <br />[] SOIL BORING # [] OVER -BORE. DIAMETER <br />[WELL # x tw -Lt> r /LCiJ -1 _ [] PRESSURE GROUT <br />[] *Other GROUT SPECIFICATIONS <br />(r,. <br />p J ii I <br />COMMENTS: �ecLu� �k�c� P%.� t�� t�PI� T-�S�fi T�c�v. �<�e� �ucte.�r /Z, z-nti`_%_ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />jj'IivIONITORING [] HOLLOW STEM DIA. OF BOREHOLE 8" [] MULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA: <br />[] EXTRACTION [] AIR HAMMER/DRIVEN CASING THICKNESS -A,L- LIc> TYPE OF CASING: [] STEEL [ PVC [] OTHER: <br />[] VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL O - ( 07 TREMIE TYPE TO BE USED: [] AUGERS [HOSE <br />I <br />Q <br />[] AIR SPARGE/ OZONE [] PUSH POINT (GP or CPT)GROUT SEAL PUMPED: R'Yes [] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30 ) <br />[] SOIL BORING [] HAND AUGER GROUT SPECIFICATIONS ��=�`� ��`^p�^+• <br />[] OTHER: WOTHER Jc:- ` APPROX. BORING DEPTH 12-0 "OLTED TRAFFIC BOX or []STOVEPIPE <br />CONDUCTOR CASING PROPOSED O (if YES, list specifications in comment section) <br />COMMENTS: Z y`rLi�ln.-a{ec- BJP<<S .Sc�`.11C7 �I%C�, j2e�` I�,<. h, .f <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 Ordiinaanges, Rules -and Regulations, and all applicable California State Laws. <br />Signed x Title/Company :S1k- 1- SG/3e-co C- j_- <br />Print Name Date <br />SITE MAP IN UNIT IV FILE, ADDR <br />WORK PLAN DATED: C <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection B <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE QNLY <br />S: Sdz /J <br />Date Issued <br />Date Final Inspection A <br />r <br />- poi <br />'2 Area <br />i� pate <br />Fir <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />a l <br />NV <br />6l0 �, <br />C�'t <br />1-25 SR# � (+( 02(P <br />C-57 ✓ WC V -WAIVER_ C-57 Letter of Authorization to sign permit ✓" Encroachment doc0%A <br />EHD 29-02-001 <br />6/22/04 <br />