Laserfiche WebLink
I> <br /> WELL � ) ERMIT APPLICATION F IM <br /> SITE <br /> I SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT ( EHD) p <br /> 304 E. Weber, Third Floor, Stockton , CA. , 95202 � IS � L51fCJ L� [�J <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED JUN 5 1006 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This aqq@@kpQQaa`` gqpprtrt��gqltt'��pp�ca with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental HealthKl�S�� rItHLI l'[ <br /> EFWWS <br /> WELL Location5Je.4K not,�46 905D Ltv.e1 Si , 56k vx P RMI7/ rcel# <br /> Cross Street City Zip Parcel# <br /> Owner <br /> PROPERTY � - 41 . _ Address J� FM '3J1 Zp <br /> Owner IAS M'� ��,tLyf,/t{]Ofr 1�,pp. City S��ppcl yr45aoZ. Phe-n1e# 209-437- 4366 <br /> C-57 Contractor wbo wa ' ll. &a Address 550 &P(A luA City11f0 V'S Zipl J5�I Lic# /04 phone# 7073*Yko <br /> Consultant / Sub Cntr <br /> S r 5 64Viro+1WnlL J TXAddr�s� GaMtm1 PFIk � 'J S City S IJ `�"�!� 95682 Phone# 53tr676 -2zF)67 <br /> GIS Coordinates: X 3Y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> H NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) ` DESTRUCTION (choose type below) <br /> II SOIL BORING # II OVER-BORE. I �A ?? \\ <br /> DIAMETER_ - lI/l V,3) <br /> I] WELL # �WRESSURE GROUT <br /> a `Other GROUT <br /> SPECIFICATIONS e <br /> COMMENTS: IVill VSC V4CWM /V4( I �jeckwi ��fM t � Ob51Y✓(�1� lQ/I U/ bpirssu.� yro� ^�, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING a HOLLOW STEM DIA. OF BOREHOLE_ a MULTIPLE CASINGS H MULTI-LEVEL WELL CASING DIA: <br /> H EXTRACTION H AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL G PVC [] OTHER: <br /> [] VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 701 TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> [] AIR SPARGE/ OZONE p PUSH POINT (GP or CPT)GROUT SEAL PUMPED: lKyes .t fl No (110TE :/-MA IM MFREE/FALL DEPTH IS 30') <br /> [] SOIL BORING [] HAND AUGER GROUT SPECIFICATIONS Mrj LOWIIA+.I 01 �i41/�� C"VI& . - <br /> [] OTHER: fl OTHER APPROX. BORING DEPTH [] BOLTED TRAFFIC BOX or p STOVE PIPE <br /> r �. J � Q CO/NDUFV CASING OP (if(If YES, �lipgt specifications in comment section) <br /> COMMENTS: � Q/Wt S- k (rt, lyf;GC x!/ 111 /lOf �iriYL1 UM GQ /•{ 4/GGf /X4114% 5 Opel l3'"W <br /> NOTE :: FF�SITE BORT GS REQUIRE ACCESS AGREEMENT OR ENCROAC VIENT PERMIT9 . <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 Or a c pRules and Regulations, and all applicable California/ State Laws. O �/ <br /> Signed x ( �/�Q( III I1 l Title/Company 64D40 ii � r � � . 7 7 7 /7 <br /> _ <br /> Print Name SW "�� hqi -ngv] Date 5- 30 ,0(� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : zy SDel v o <br /> WORK PLAN DATED : I O I I I r7 Z <br /> Application Accepted ��B/yJ/ w. Date Issued 6I 10 (oArea <br /> Grout Inspection By t�l� AA DatP62h / Ot7 Final Inspection By - <br /> Date L <br /> Destruction Inspection By Date 6 ate o �1.. <br /> COMMENTS / CONDITIONS: Cas 1riv 07r/� 4enyirZt iT 6T � IS O <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED7 CHECK # RE��C''gD BY DATE PERMIT SERVICE REQUEST # INVOICE <br /> 3 !5 -03 . aa <br /> 3s o3 103 / I � 6 ( 7It7j'i S� L1b Z-9 <br /> � z7�. 00 <br />