Laserfiche WebLink
San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.or /thd 5 <br />Well Perm't A <br />ORIGINAL <br />SITE <br />ITIGATION <br />UNIT IV <br />I pp Ica Ion <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATbl �l�,t i1 VI . $ 1 AL <br />�-c�„�Ti'iEPdT <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work degli"iL 4-11 s -'application is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin CountyEnvuonmental Health Department. <br />F L 001'0917() S � ' � L '00"4/30 C' Assessors <br />WELL Location 3 / / 7 S c Cross Street !� City S'TaC K!n ^Zip 5q 2 ab parcel# !1'%.S / 2 UO3 <br />PROPERTY T°'JN�C S, �, (, <br />Owner— CnLiFonv,q Lj,IE5 Address 02000 City _100(_ �'-,Zip9157ZQL phone# toy C (p ;ass t/ <br />T RA1vi"do <br />C-57 Contractor /t 5 T � M f f i (4 G A ff ddress jl�j w ;��„� c, QQ. City CoA ip 95) ` L- Lic# 9 Sd Phone# 91 � 6 j _ 5 6 y <br />UU T ' <br />Consultant / Sub Cntr A Address v l R City SrD( K” Lic# � phone# z U � b / 1)9 <br />GIS Coordinates: X , Y Township Range Section <br />AID# <br />WORK TO BE PERFORMED: <br />FAC# <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) DESTRUCTION (choose type belovf) <br />S <br />0 SOIL BORING # VER -BORE. DIAMETER-/ J �v <br />0 WELL # <br />\ <br />-+� <br />0 "Other 0 RESSURE GROUT <br />DATE PERMIT VEST # INVOICE <br />GROUT SPECIFICATIONS <br />COMMENTS: % I /1e./4 &0 W o R IC !'/,,,gL / 09 T f�d J✓ 1 v �� <br />- -- <br />Q\\. <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />r— <br />MONITORING \; HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />z717 <br />0 EXTRACTION Sc� e0\'�( <br />AIR HAMMER/DRIVEN CASING THICKNESS 10 TYPE OF CASING: 0 STEEL`,PVC a OTHER: <br />0 VAPOR c <br />MUD ROTARY 'i <br />0 DEPTH OF GROUT SEAL J TREMIE TYPE TO BE USE $AUGERS 0 HOSE <br />SR# <br />0047307 <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: es 0 No NOTE: MAXIMUM FREE -FALL DEPTH IS 30' ) <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATION �4 l % )A,D %y4 -e <br />Q <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH_ SS 0 BOLTED TRAFFIC BOX or 0 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, Rules and Regulations, and all applicable California S to Laws. % Q <br />Signed x / fM �1�i�°H�p <br />Title/Company CL 7 S / <br />Print Name / 1 M l y 2 Date ej % / (�,� 14/ <br />DEPARTMENT USE ONLY T_ / <br />SITE MAP IN UNIT IV FILE, ADDRESS: 3147 S. El lD O 1'a pt o S+re e � <br />WORK PLAN DATED: Julv 5. 2 -pal, <br />Application Accepted By c+o c,+r i'CL , e Date Issued __�G 2 0 0 C Area 4 $- <br />Grout Inspection By i 4- iil Date ?. -O Final Inspection By 54.y22 Date <br />Destruction Inspection By Vi c.+t Y, a ftj t, &V P y Date 7 -.2c) - O ( <br />COMMENTS/ CONDITIONS: e i- r G i o� n -F 1'n f>, ; r; CA wt --j <br />IA/- q <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT VEST # INVOICE <br />3,503 <br />z717 <br />339. Oa <br />SR# <br />0047307 <br />%--vvk,= wAivtK_ G -n/ Letter of Authorization to sign permit_ ncroac ment doc <br />EHD 29-02-001 <br />6/22/04 <br />