Laserfiche WebLink
a Sth Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor,Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> trF N`P Well Permit Application <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. t <br /> /� G L // Assessors <br /> WELL Location -5u (<Tc,ez /rive cross Street GGs! ity ! 7& K 12 Zip 9S° �Parcel# <br /> PROPERTY, <br /> s <br /> owner „ Atd�d'r�esas vwy <br /> Phone#Cltyip J5&2 <br /> cityg4. . a Zip�Lc#233 '9Ph-oYne6#b� <br /> �"O <br /> C-57 Contractor e4 � ae ddress <br /> fn / <br /> Consultant/Sub Cnlr IL kL Address LOST(, ,i�I SJ/r rf CityCr,.,,frLic# �Phone# <br /> a I Sl <br /> GIS Coordinates:X ,Y ,Township Range <br /> Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) EST-BORE. I (choose type below) <br /> U SOIL BORING# O*.ORER-BORE. DIAMETER <br /> WELL# GROUT SPECIFICATIONS <br /> � GROUT SPECIFICATIONS rtEatc,.,....q <br /> p*Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS u <br /> t'�ONITORING n HOLLOW STEM DIA.OF BOREHOLE n MULTIPLE CASINGS 0 MULTI-LEVEILWELL CASING DIA: <br /> n EXTRACTION a V HAMMER/DRIVEN CASING THICKNESS () 33 7 TYPE OF CASING: a STEEL OVC 0 OTHER: <br /> u VAPOR Y✓MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS rfiOSE <br /> g AIR SPARGE/OZONE p PUSH POINT(GP or CP-F)GROUT SEAL PUMPED: I(Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING E HAND AUGER GROUT SPECIFICATIONS &e Ak t e� OLTED TRAFFIC BOX or STOVE PIPE <br /> OTHER: n OTHER APPROX.BORING DEPTH <br /> if YES,list specifications in comment section) <br /> CONDUCTOR <br /> CASING PROP/OSED (, <br /> COMMENTS: Pi�4s C C r✓,..SiY h i �etA•(� �n�Ws <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. Y <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/ Laws. <br /> Signed x Title/Company -S 7 Je. <br /> Y.s <br /> Print Name lo✓ r• rr u/Pl Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED:II B q G , <br /> Application Accepted By oY � Dale Issued ?/, 0 Areal <br /> Grout Inspection By .0 9-(iP Date Final Inspection By jg / -&A�LDate V--'g <br /> Destruction Inspection By Date I< <br /> COMMENTS I CONDITIONS: S vL COSTA- �� '`Pr <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 2 9-oz 60 . 1,o- I o8�r� � <br /> C-57_ W(_-WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> ERD 29-02-001 <br /> l 622/04 <br />