Laserfiche WebLink
Date Issued <br />Final Inspection By <br />Area 0(71 <br />Date <br />C-57 WC 9/30/02 -WAIVER C-57 Letter of Authorization to sign permit <br />ACCOUNTING ONLY: AID# FAC# <br />e. <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE ERMIT / SERVICEREQUgT <br />ice)/ 35 - P' 17/717 (J-(-- //T/OR# 0031z- s- <br />10/08/2002 10:47 2094683433 FIFTH FLOOR PAGE 04 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR mom DATE ISSUED <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 />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br />Assessors WELL Location fit -i.i0/3 E. Stir r 4 .re" ta Cross Street TdInrk rdtk 41r, City 1.-.0d; Zip "PY-.0 Parcelff <br />PROPERTY Owner , ,Ate /9°/Z „Li& • Address /,62 S 3At City 1-44 / Zip Y-41 Phone# <br />C-57 Contractor j 1)r )) tie Address 96-6' e irve City Math", eL Zip Lic# 615-007 Phonert 025)341 -5e00 <br />3-0 5-.97\ (0.1,arret.i,1 eari.ty /../"Atc,rot Lic# Phone# 0725--)iree- 0 Consultant / Sub Cntr TR Address <br /> <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />XNEVV WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />)(SOIL BORING # <br /> <br />WELL # <br /> <br />*Other <br />COMMENTS: <br />SITE <br />MITIGATION <br />UNIT IV <br />O DESTRUCTION (choose type below) <br />OVER-BORE. DIAMETER <br />a PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />fl MONITORING <br />l] EXTRACTION <br />El VAPOR <br />El AIR SPARGE/ OZONE <br />XSOIL BORING <br />El OTHER: <br />COMMENTS: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />)KliOLLOW STEM DIA, OF BOREHOLE,. e- fl MULTIPLE CASINGS a MULTI-LEVEL WELL CASING CIA: <br />AIR HAMMER/DRIVEN CASING THICKNESS A /A TYPE OF CASING: a STEEL PVC a OTHER: <br />n MUD ROTARY DEPTH OF GROUT SEAL `7a TREMIE TYPE TO BE USED: U AUGERS ['HOSE <br />PUSH POINT (GP or CPT) GROUT SEAL PUMPED: gYes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />n HAND AUGER GROUT SPECIFICATIONS Niq eeft.e41 <br />fl OTHER APPROX. BORING DEPTH 70 Pt. U BOLTED TRAFFIC BOX or B STOVE PIPE <br />CONDUCTOR CASING PROPOSED iv (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 />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County 0 dinances, Rules aJ Regulations, and all applicable California State Laws. <br />0 A.404,14____74.5 7-TZ.x— <br />Print Name DEFIN S /2°4' 6-err Date I ()4 C)3 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Signed Title/Company <br />tkpplication Accepted By (.< 44%----4---(- <br />..-3rout Inspection By h.1 k.-,&_.t Date / 0 <br />Destruction Inspection By Date <br />OMMENTS I CONDMONS: