Laserfiche WebLink
Signed x <br />Print Name icsErit RAMIkc-E <br />San Joaquin County <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 tivviiii,Lotvim1EN6TMHEb4LELIT:4 <br />IT IV <br />1)AETION <br />Environmental Health Department <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehdpci3mirisosm <br />Well Permit Application <br />N <br />CES <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 />C0ViNITY 0 "14;, , Assessors WELL Location 1-1-7- ef WE 13 A .‘ NM Cross street SAN 46 AQVINcity StoC KION Zip 9Szoi. Parcel# J zi4 /6.0 0 / 5IfteEr PROPERTY SAN TOAQViN COVNI1 <br />Owner FALILIII“ M6-MI- 1).-FT• Address I 2L SCGII5 AV ri City STOCKTON Zip 9 Sla 5 Phone# (7.09 )46 13-962S <br />C-57 Contractor VKILLINCi- Address 9 50 t4 ONE. RP City IIARTINVk Zip 94 S Lic# 6 S6 LIOIPhone# 9 1.0 3t3 - S800 44/5 5.. tit,eocw5 tviS 151 Consultant / Sub Cntr KAMA Crt. t NV ) INC. Address No, City 4V Lic# AG-5856 Phone# 01-s ) 8 Si -1Z 33 <br />GIS Coordinates: X <br />Section <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />, Y , Township Range <br />WORK TO BE PERFORMED: <br />I NEW WELL / BORING .(CPT, GEOPROBE, HYDROIONti HAND-1UNR,AIR*) <br />9 *Other <br />II SOIL BORING # CPT -I 0 WELL # <br />COMMENTS: <br />16 (i DESTRUCTION (choose type below) <br />0 OVER-BORE. DIAMETER <br />PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 1.'' a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: NA 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS N A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Ni TREMIE TYPE TO BE USED: 0 AUGERS 9 HOSE <br />I SOIL BORING 9 HAND AUGER GROUT SPECIFICATIONS NriAt CEMENT <br />. [I OTHER: 0 OTHER APPROX BORING DEPTH <br />0 AIR SPARGE/ OZONE I PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />dig / El) BOLTED TRAFFIC BOX or 9 STOVE PIPE <br />CONDUCTOR CASING PROPOSED N 0 (if YES, list specifications in comment section) COMMENTS: f:ANI4li-E- E.I4V RiliSET) VJVAIN PLAN ( 3 itt )0C) <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 Ordarkces, Rules and Regulations, and all applicable California State Laws. <br />Title/Company PR ElptI,IT/ RatifiCrE E.NViRcINMNIAL, ING <br />Date it <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />Application Accepted By si./..-drdid„. (717e_. Date Issued O2.+-6 lo PA' J 7 La 0 <br />. . <br />„ Grout Inspection By Vi clay: 4 L. filt(ar+ytt Date ) 0 7 Final Inspection By Via-Or/4 ii/C-C,4y9SsUyte <br />Destruction Inspection By Da e <br />WORK PLAN DATED: AUS u,5 -1- 4i ZOOG <br />DEPARTMENT USE ONLY <br />22Z EaS+ Weloezr Avenue <br />Area <br />COMMENTS / CONDITIONS: Aci vanCemerL+ of a 11 e. Carte. p e.ri G+ r tP Y; Kt , CPT"- . <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT V INVOICE <br />35-401 <br />35o 3 abs- 37+ <br />C-57 <br /> <br />WC -WAIVER <br />C-57 Letter of Authorization to sign permit-----Emr-oadzwitskc.„-- <br />EHD 29-02-001 <br />6/22/04