Laserfiche WebLink
Signed x <br />Print Name ‘‘INk• <br />San Joaquin County S1,or, nuArrs <br />Cc Oak. Her <br />to Cairewvi rit.:vor) <br />Environmental 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 /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ORIGINAL Well Permit Application <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 />Joa uin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />'71/-1-)4 19,, , Assessors <br /> <br />Cross treetoceoutiA I) r. City 12-1c,r-1 Zip .7531,1, Parcel# -e k t 6 AV' <br />PROPE a 59 A/ le; imei 4 ve I epo, 9$-3G6 ,2 • - 599- <br />Aciaress9-30e-MOTA`b, City 910914:66, Zip_Phone# Owner <br />C-57 Contractor &gen Nal) Address 19) Hat, . City %OTC. Zip 7Igs3 Lic#995/Or'hone# 4,25-4/9"SPrk, <br />Consultant / Sub Cntr UititAbiel Address5"0 MOS st.sicA City 141-0S-97-Phone# 67a if20131 3 <br />GIS Coordinates: X <br /> <br /> , Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />INEW WELL / BORING GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />gSOIL BORING # 0 OVER-BORE. DIAMETER <br />[] WELL # 0 PRESSURE GROUT <br />U *Other GROUT SPECIFICATIONS 6 <br />COMMENT.i.?xj&Vi 1.4)cabem 15 CrY) 641 (2.-1 *Wei . NAL ref n1;44(44 bli C; tl t>c. 1e-1 001 <br /> <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> <br />a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL 0 PVC 0 OTHER: <br />0 VAPOR <br /> 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS U HOSE <br />0 AIR SPARGE/ OZONE U PUSH POINT (GP or CPT)GROUT SEAL PUMPED: g Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> <br />SOIL BORING <br /> HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH U BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <br />C13.1 eriCAVACIVY1e."-+ 1%41Y VOI 1 Obkai rvc( aet 121 i ctoe <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 Ordinajices, Rules and Regulations, and all applicable California State Laws. <br /> Title/Company Gr . <br />Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: —1k. .h t-0 idet,f/ Fran 1 e- gd . 1--atte. R 0 I.) )-e E <br />COMMENTS / CONDITIONS: 0,1E- CP I. 1)11 r )1.1 e Cg J chf Ik?ol <br />ACCOUNTING ONLY: AID# FAC# <br />(... <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT I-SERV1 # INVOICE <br />35-0 / 89 S'74-. 0 0 (o IIIIIII SR# O 49 G9 <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit <br /> <br />en doc <br /> <br />MITIGATION <br />UNIT IV <br />WORK PLAN DATED: /7k2q 01 .4/2 <br />iee4 r Application Accepted By <br />Grout Inspection By II' <br />Destruction Inspection By <br /> <br />Date Issued <br />Date 0 7 Final Inspection B <br />Date <br />EHD 29-02-001 <br />6/22/04