Laserfiche WebLink
San Joaquin County <br />Envii �,imental 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_.''h C, I� <br />�-._. <br />Well Permit Application <br />SITE <br />MITIGATION <br />UNIT IV <br />MNY 1 9 2007 <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. Thusppli�atidn' isriiace' ill ✓rtirhpliance with San <br />Joaquin County Develo men ITdle, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Heafth Department: <br />Z60d f a . I Assessors <br />WELL Location - lir A01 -4 4X ` Cross Street {� City ( loc�� o'A Zip `f ;26Cc Parcel# 7 <br />PROPER C �i' J a+ Sto ejGtry, S 21 /O 7 <br />S N. CI oraaroSt. S-zaz G <br />Owner a�r Address � Cityc�(o� ZipPhone# (7611) y(,7 <br />C-57 Contractor AC• c / F , -n a4e _ Address '9n S w RQ1. City Zip ,� Lic# c7-2-7 Phone# (2o9) x(67 -1(Y) <br />Consultant/ Sub Cntr ,4\ra,ie2J ddress 43 �;7 9-. - City S+�,I�k,.� Lic#.ZZ h <br />AMR <br />GIS Coordinates: X Y Township Range i <br />WORK TO BE PERFORMED: <br />WELL / 00 RING(CPT,(GEOPROB ; HYDROPUNCH, HAND -AUGER, OTHER") 0 DESTRUCTION (choose type below) <br />SOIL BORTIqG # 3 0 OVER -BORE. DIAMETER <br />p WELL # 0 PRESSURE GROUT w\ <br />0 "Other GROUT SPECIFICATIONS 6 <br />COMMENTS: -s na �G a�•_ �a� cc�a� _ O <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS W <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE , 25: 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS a TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: T <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL y c� TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE )1PUSH POINT GP or CPT)GROUT SEAL PUMPED: 0 Yes )#No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 4�g, r/lam <br />/0 OTHER:_a OTHER APPROX. BORING DEPTH �i S` 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED n e. (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 State Laws. <br />Signed x_ 00 Title/Company Si�i� �9eo�ogfsl �,4 E <br />Print Kame �`l Date <br />DEPARTMENT( USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: Seu+b 5,'d a of .2DD d block. e f M'1y2 ? e!t Road <br />WORK PLAN DATED: Fe�br tA a r L4 . ) (. Z 6 0 ? <br />Application Accepted By V clo r ALL _ . Q� kl grT�?�. Date Issued $ -?S -0'7 Area JA S <br />Grout Inspection By V I1;7mc� %i1B�lir'�7l.ev� Date I -h� Inspection By Yict'dYiLri%1C�sr� ate % — 3"O 7 <br />Destruction Inspection By Date <br />COMMENTS/ CONDITIONS:'44v Q7 �6 a <br />' r. vt' j3 ` 9 <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT / SERVICE INVOICE <br />aso3 <br />ze's <br />37�'•� <br />?s7a <br />SR# dD5-D S� <br />C-57 WC= WAIVER_ C-57 Letter of Authorization to sign permit Encroac > en -doc <br />EHD 29-02-001 <br />6/22/04 <br />