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 />0 <br />(l� SITE <br />ITIGATION <br />06.; 2 UNIT -IV <br />Well Permit Application�y-Vj �9;1 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pC,q oIVI��J% <br />� . <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is madeHFA in co,-,mpliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. y� / <br />WELL Location �5 L o VISA. Ave • Cross Street-, - 5' city �ti10 zips( 33o Parcel# Assessors <br />116 -? -2 `! 0 <br />PROPERTY <br />Owner 9Pye/ k (A>mt PfOdU(& Address � I Xc 1444 J)". City lmt Zip iWZ3 Phone# YZ5- Z%5-3$kj <br />C-57 ContractorWoya(yo-� i�/�l�i^�f �• Add'ress%> RIV& W City -'0 U, Zip qt 71 uc#7/ou1 Phone# 7y7-3�y N,�oa <br />Consultant / Sub Cntr L S Futth(i/I� �1I+1�+�l Addres 3� � W14M P� D , ci y5° Caw+ PL c#K� � 45�$Z phone# S30 -i 7G-206 2 <br />GIS Coordinates: X , Y Township Range Section <br />AID#rr <br />FAC# <br />WORK TO BE PERFORMED: <br />p NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') DESTRUCTION (choose type below) <br />FEE INFO <br />o SOIL BORING # VER -BORE. DIAMETER_ /0 <br />CHECK # <br />a WELL # a PRESSURE GROUT <br />PE IT / SERVICE REQUEST # ICE <br />a *Other GROUT SPECIFICATIONS <br />35 02 <br />COMMENTS: <br />bp_oaL3`6 <br />91 <br />t4 io z3/q- <br />SR# 5 Z 3-3 <br />G <br />TYPE OF WFLL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />ll <br />MONITORING OLLOW STEM DIA. OF BOREHOLE 1011 a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: y _ <br />a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br />o VAPOR a MUD ROTARY DEPTH OF GROUT SEA aL_TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />a AIR SPARGE/ OZONE p PUSH POINT (GP or CPT)GROUT SEAL PUMPED: )ryes Q No• (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS (40"—'VA <br />a OTHER:_ fl OTHER APPROX. BORING DEPTH aIO�-2Y 1 a BOLTED TRAFFIC BOX or a 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 State Lawns. <br />/ I n <br />Signed x JcLAa <br />(Q 'I^I1 - Title/Company� _� j15�, J�/tt1YS FNvilorlottitw, TF, <br />I <br />Print Name Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE,jDDjESS:_ <br />WORK PLAN DATED: `I I`j0 <br />Application Accepted By Date Issued i 3 6 Area <br />Grout Inspection By 1,DtL,vU-'rr , Date Z O Final Inspection By Date Z d <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID#rr <br />FAC# <br />/ - 7 <br />_ls' C C ' <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY DATE <br />PE IT / SERVICE REQUEST # ICE <br />35 02 <br />bp_oaL3`6 <br />91 <br />t4 io z3/q- <br />SR# 5 Z 3-3 <br />C-57 WC --WAIVER C-57 Letter of Authorization to sign permit ✓ Encroachment doc_ <br />EHD 29-02.001 <br />6/22/04 <br />