Laserfiche WebLink
San Joaquin County <br />Environmental Health Department <br />600 E. Main Street, Stockton, CA 952�Q��' <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjg gTe� LUf <br />Well Permit Application MAR 1 7 2008 <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES " YEAR FRO�,�;Ta ISSUED' •' T <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the wb>`EOesCrj4d4 fR�1$, apptication is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Healtli-Department. <br />Assessors <br />WELL Location 2122 %,1441 Ar;Q0r+ 14Y.Lu Cross Street 21, .4y -elf City Npck+nn Zip 5�?Parcel# 11oq-7(o 2 •01 <br />PROPERTY <br />Owner Ra1nh Loh i -It Address 2263%A 4&0 &)OU City 4FD6k.&D ZipgS2acp Phone# X09-410/437/ <br />C-57 Contractor MikheliDn Address -790y 14rirI&& r)w cityCUylko Zip �S'�Lic#1,72GI•lPhone#'104-Lill q-`/tJH& <br />Consultant/ Sub Cntr Klrl aaor1(,mtLnarY14*ri ji IxAddress III MALI) IEOd City i%�Lic# bY0321 Phone# 00-4110-11-100G <br />GIS Coordinates: X <br />Y <br />Township <br />Range Section <br />WORK TO BE PERFORMED: <br />-RNEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND_ AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />RWELL# MW -1., Mwd.' mto- f MW -!U, HW -11 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING 1XHOLLOW STEM DIA. OF BOREHOLEF3,'25!' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 4PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ?Ipl QYk! 951 TREMIE TYPE TO BE USED: 0 AUGERS .HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: gYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Ti r3e- 'I11 F brfIQn6 &I'M11i <br />0 OTHER: 0 OTHER APPROX. BORING DEPT H S7�'QjInd I 10' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED NO (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 Ord)�ances, Rules and Regulations, and all applicable California State Laws. <br />Signed x`'1V Title/Company1/IceTi-tS)C�PtI��11cluayiceetI'dnEnwebinmeii�,biC. <br />Print Name i r`mF. Mdr�u_ Date -ILA ,Q <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: Z I z Z 5 • A-� agN - Ljc './ bio i wi <br />WORK PLAN DATED: lz I -,?,A I n -Ij <br />Application Accepted By (Zj� ...�� Date Issued 3 I I X10 5", -Area <br />Grout Inspection By l,l..,.s., Date 3 19 a -.r Final Inspection By Date Z-1 f o <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />V! <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT/ SERVICE REQUEST # <br />INVOICE <br />35-01 <br />—v3 <br />9 &R'od <br />2c1y.oy <br />265 }� <br />��►Klcg <br />SRO rj 3(03`1 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit, Encroachment doc_ <br />EHD 29-02-001web <br />6/22/04 S b O / 3 } _> <br />