Laserfiche WebLink
San Joaquin( County <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 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM nATF IseuFn <br />Application IS hereby made to San Joaquin County for a permit to construct andlor Install the work described. This application is made in compliance with San <br />Joaquin County Development Title, Chapter 8-1115.3 and the Standards of San Joaquin County Environmental Health Department. 8 <br />WELL Locatlen Y Y l O Cross Street 1�[li LCL ' Cit Zi Aa3c3310n 1 <br />y p G��Parrol# <br />C-67 <br />Consultant (Sub <br />GIS Coordinates; X <br />WORK TO BE PERFORMED: <br />city r 1p�rTry I'nonett �� <br />Cltyt -Y�,,*1 _ . Phone> - <br />Township Range Section <br />NEW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") p DESTRUCTION (choose type below) <br />Q SOIL BORING #� ALR BORE, DIAMETER <br />PV <br />III WELL #���� n PRESSURE GROUT J <br />0 `Other GROUT SPECIFICATIONS <br />COMMENTS: �.1 <br />TKEg OF WEAL IN,9TALLATION TYPE CONS ERVCJION SPECIFICATIONS <br />III MONITORING I HULLOW STEM DIA. OF BOREHOLE <br />�^ a MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS PE OF CASING: 0 STEEL J PVC p OTHER: <br />n VAPOR n MUD ROTARY DEPTH OF GROUT Sr --AL 9, S- r _ TREMIe TYPFz TO BE Ustu• I AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE n PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Q Yes a No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SAIL BARINGp HAND AUGER GROUT SPECIFICATIONS f 4Q �l r <br />0 OTHER:_ 0 OTHER. APPROX. BORING DEPTH #BOLTED TRAFFIC BQ or 0 STOVE PIPE <br />COMMENTS:CONDUCTOR CASING PROPOSED /1% (if YES, list specifications In comment section) <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ord.n� es, Rules a ulations, and all applicable California State Laws, <br />Slgned xi <br />Titl®!Company � I ` <br />Print Name Date fp <br />DEPART ENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: �$TM L a rC —Rd. <br />WORK PLAN DATED:_ + I— <br />Application Accepted By - Date Issued 1 0 L Area 1 S <br />Grout Inspection sy hat., Final Inapcction t7y [fate 2 Q <br />Destruction Inspection By Do <br />COMMENTS/ CONDITIONS; , 6 b r A of - 2 2 -and IM W :-2-� <br />ACCOUNTING ONLY: AID# FAC-# <br />PF CODES FEE INFO AMOUNT RIILMITTED CHECK # fi G'D BY DATE PE EQUE5T # INVOICE <br />3s03 �Q 394. RS SR# <br />C-57_ WC --WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc --� <br />EI -ID 29-02-001 <br />6/22/)9. <br />