Laserfiche WebLink
Environmental Health Department SITE <br />V[0 MITIGATION <br />UNIT IV <br />FEB 0 6 2007 <br />304 East Weber Avenue, 3rd Floor, Stockton, C <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sig <br />Well Permit Application <br />lor-eX <br />Address /15A4- 600er —&-&7-etrntractor City Zip Lic# Phone# <br />90vo Oeppriptil im <br />Consultant / Sub Cntre,arni2ria P;rwircrovnikldress u City kavie Lic# phone#/qua7I-3407 <br />GIS Coordinates:JAI: 37. 7177 ,,La4j: -/z/..Z343 ,Township Range Section <br />Owner <br />PROPERTSJ <br />Address ?/ City, Zipgag'honet <br />)I( COMMENTS / CONDITIONS: <br />Application Accepted By <br />Grout Inspection By Date <br />Destruction Inspection By Date <br />< /0 1 (The- Vt. <br />Date Issued <br />Final Inspection By Date 5 -7- 67 <br />Area e6 <br />San Joaquin County ORIGINAL <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAT EMFAMEN T HEALTH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work descpfcf4A frihApp#Otk is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental't-rda1th 1ie4ptment. <br />Assessors A A <br />WELL Location 19511[66-k, Ave. Cross Street /ill Oil Cci• City iviame Zip q5S37 Parcel# UU 166-15 <br />WORK TO BE PERFORMED: <br />''NEW WELL! BORING <br />0 SOIL BORING # <br />0 WELL # g*Other <br />COMMENTS: ea <br />(CPT, GEOPROBE , HYDROPUNCH, HAND-AUGER, OTHER") 9 DESTRUCTION (choose type below) <br />0 OVER-BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />nel kirelallr/M-4iff-3 vow phikrt -iv lo <br />TYPE OF WELL <br />0 MONITORING <br />0 EXTRACTION <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br />INSTALLATION TYPE <br />0 HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 311 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS 010 TYPE OF CASING: 0 STEEL 7(PVC 0 OTHER: <br /> TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS -40') <br />1SOIL BORING 1(1-IAND AUGER 1 n/ GROUT SPECIFICATIONS 6" lir rfprjrkicialyi hr) 5' bentriikChydo-ire0 <br />OTHER: IL, 0 OTHER < MIV APPROX. BORING DEPTH* 69 4b9 )(BOLTED TRAFFIC BOX or 9 STOVE PIPE <br />CONDUCTOR CASING PROPOSED Ato (if YES, list specifications in comment section) Q,,, 1 1 ik <br />COMMENTSVI 1 tiailY rolA asil ix brcint-4-e4 0 pia I attMotrig wiliiii attrilm'a5 --tin 6,2-007 <br />5oi( inve -hat-) WolLpLA() . <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 prepar d this application and that the work will be done in accordance with San Joaquin <br />County OrIj ance , R le d ulations, and all applicable California State Laws. <br />6i-eolt13-i-/ Ixig Erwin-mai* ,---- - <br />Signed x Title/Company <br />Print Name ndin Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: /7 5-7 ti/- .f?) <br />WORK PLAN DATED: --S-07 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK #REC'D BY DATE PERMIT / SERVICE REQ I - T INVOICE <br />5(9( 6B a el i5.,/„..i ,,,,,, „A SR# 106116 , 2, <br />,. <br /> <br />WC -WAIVER <br /> <br />C-57 Letter of Author.zation to sign permit <br />Muz.d P6 • (57b: <br /> <br />EHD 29-02-001 <br />6/22/04 <br />