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.org/ehd <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />Well Permit Application ��i/'' /1 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED V (�(� 1 w <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 />Joaq n County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />-ate ��/7 / lez woo _/ / / /. Assessors o R / <br />WEL Location c 7 v� ^,ross Streei f A'k1A1U/_ City aNc c5c�r�cn Zip r1 `) C�`i Parcel# (�C_l (i!/ <br />PROPERTY / / p <br />Owner C���'� t'�0 Ak4ddress <br />�C 6"-City <br />�MZip �Phoonne# <br />C-57 Contractor Add40ia FC— 62Cdty�/ljdA q/1 1DPhone#Q1 <br />1 61 <br />Consultant/ Sub Cntr 'b13L Address k0CA1-1:) 0,,CA City Sc.c}c Lic# Phone#hk't.i Vi1 - <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />PE CODES <br />Q NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) Q DESTRUCTION (choose type below) <br />Q SOIL BORING # <br />Q OVERBORE. DIAMETER <br />•g WELL # <br />(]'Other <br />Q PRESSURE GROUT <br />GROUT SPECIFICA IONS <br />COMMENTS: <br />Fog <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPEC ICATIONS <br />MONITORING k1HOLLOW STEM <br />DIA. OF BOREHOLE (] MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br />Q EXTRACTION Q AIR HAMMER/DRIVEN <br />_ <br />CASING THICKNESS ,k4V TYPE OF CASING: Q STEELVC Q OTHER: <br />Q VAPOR Q MUD ROTARY <br />DEPTH OF GROUT SEAL— 2S� 60 TREMIE TYPE TO BE USED: AUGERS Q HOSE <br />Q AIR SPARGE/ OZONE Q PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />Q SOIL BORING Q HAND AUGER <br />GROUT SPECIFICATIONS—'— <br />Q OTHER: Q OTHER <br />APPROX. BORING DEPTH So 75 Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <br />r C,- <br />,—NOTE: <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 State Laws. <br />Signed x c w�� M�-.�.� Title/Company �4 :3 Q r�)r; 'y� 2,9,0— <br />Print <br />39,0— <br />Print Name -T0YN� N '' Date Lt"( Ob <br />DEPARTMENT USE ONLY 35,0 <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DA <br />Application Accepted By <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS / CONDITIONS: <br />Date <br />Date Issued <br />Inspection By <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE' ERV <br />INVOICE <br />Fog <br />�/D D SR# 91-�_7_ <br />C-57 V WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroac men oc �Olo-�tiv/Ge <br />EHD 29-02-001 <br />6/22/04 <br />