Laserfiche WebLink
San Joaquin County <br />Envii mental 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 />Well Permit Application <br /> <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <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. 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 />7, Assessors <br />WELL Location 10 7 1\,Scit_s)1 Cross Street -LI Pt-S ( City Zip:952g- Parcel# <br />F°71:r" 8 (/ P ) )2- (1-6Ad dressl4??1) <br />- G' ?tLi") cjicc / f - D 9 .c152 4 X' - / /4 ? Zip Phone# <br />C-57 Contractor . 6 el Address 6 - -) S' L) a citysx...y,061 Zip0-52 I •-ic#°61:22 7Phone# 161 / odo <br />Consultant/Sub Cntr 4- c_--7 Address City <br /> <br />Lic# Phone# <br /> <br />GIS Coordinates: X <br /> <br /> Township <br /> <br />Range Section <br /> <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING, (93T, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />OIL BORING # et> <br />/U WELL # <br />B *Other <br />COMMENTS: Si.," .5-16 <br />0 DESTRUCTION (choose type below) <br />a OVER-BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE Oivt.A1 MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA <br />rZ) <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL U PVC U OTHER: <br />0 VAPOR UM1D ROTARY DEPTH OF GROUT SEAL -5:6" tr-e-I-TREMIE TYPE TO BE USED: U AUGERS U HOSE <br />/60IL BORING 0 HAND AUGER <br />0 AIR SPARGE/ OZONE PUSH POINT ( <br />B OTHER: 0 OTHER APPROX. BORING DEPTH )75-,--5- BOLTED TRAFFIC BOX or ['STOVE PIPE <br />CPT)GROUT SEAL PUMPED: U Yes /a/No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS <br />COMMENTS: <br />1-47 CONDUCTOR CASING PROPOSED (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 Ordinances, Rules and Regulations, and all applicable California State L ws. <br />Signed x 0-60,44. Title/Company ez: ?-17C- <br />7/11 ) 01-r1 Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: dliz.8 Jo <br />DEPARTMENT USE ONLY <br />I OThScAt59( • <br /> <br />Print Name <br />Application Accepted By MA-- <br />Grout Inspection By cs,/k._-'11.-N.A"-^-c"... Date t I 2.'410 <br />Destruction Inspection By Date <br />Date Issued 1,12; k _6' Area al ,, Final Inspection By v _Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# F <br />_ <br />5-R to y 6 - -- 40 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PER' - - 0 1 EST # INVOICE <br />3 5'a I <br />35-03 <br />lb Tr ct•oc, <br />I 2-7-cf.oe <br />2-3‘f 12_ Ora 11,2106 sR# LI s Li 49 <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />EHD 29-02-001 <br />6/22/04