Laserfiche WebLink
FILE COPY <br /> San Joaquin County ° '����rrr--- UI'-1 lv/E®__ <br /> L��y/ �nl <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 952IX i 2 7 2006 MITIGATION <br /> K` (209)468-3449 Fax:(209)468-3433 Web: www.sjg'ff0i/%MEN1HEALTH UNITIV <br /> Well Permit Application PERMIT/SERVICES <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 Mile,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> AsseWELL Location ,(3 y,1.• /.L�(a/l Cross Street 1111{`' S} City Ir.�,Zip L5_o4 Parcesta�'2.52-Q�a�Q3 <br /> PROPERTY f(-- ilarlye..� ro-r—,(,UP�eI 511690 <br /> Owner Unren P41AI Address0 u S City OwrA�'1 q,N ZIP Cog 17&A Phone# <br /> c-ST Contractor r 'n Atlaress 22D . Eos! $1 cityoocl AhjZip0.5776 uc# Phone# 530 -7 -Li <br /> Consultant/Sub CnV ShIC. Address 3800 Wails�1"'C ucr4na..t"rp Phone# 1 —3500 <br /> GIS Coordinates:X ,Y ,Township C t s Range Serdlon X <br /> WORK TO BE PERFORMED, <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) B DESTRUCTION (choose type below) <br /> SOIL BORING# ? U OVER-BORE. DIAMETER <br /> B WELL# B PRESSURE GROUT <br /> B•Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ./. <br /> B MONITORING n HOLLOW STEM DIA.OF BOREHOLE_1.1r.B MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> B EXTRACTION aAIR HAMMER/DRIVEN CASING THICKNESS &11& TYPE OF CASING: n STEEL D PVC n OTHER: "'- <br /> B VAPOR B MUD ROTARY DEPTH OF GROUT SEAL '90T+ TREMIE TYPE TO BE USED: ]]AUGERS n HOSE <br /> 0 AIR SPARSE/OZONE BPUSH POINT(GP orCPT)GROUTSEAL PUMPED: Byes Po (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING BHAND AUGER GROUT SPECIFICATIONS.__ NEAT- CeAAgpyrr <br /> B OTHER:_0 OTHER APPROX.BORING DEPTH 30 f-r n BOLTED TRAFFIC BOX or B STOVE PIPE <br /> CONDUCTOR CASING PROPOSED A.10 (if YES.list speolfications in comment section) <br /> COMMENTS: <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 Ordin n.e,n Rules and Regulations,and all applicable California State Laws. <br /> ,jSignedx Title/Company Sf* ''Gcel�Jrsf .Sri•/L <br /> Print Name tl'11G1 T Date ff 2 OCA <br /> DEPARTMENT USE ONLY / <br /> SITE MAP IN UNIT IV FILE,ADDR SS: S6 S. , .fit !�-�' G ll2u��+a 29.6 <br /> WORK PLAN DATED: Z°) <br /> - Application Accepted ByDate Issuedza 5s inn <br /> Area <br /> V Grout Inspection 8y to Final Inspection Sy "'s <br /> Destructlan Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMOUNT REMITTED I CHECK# RECD BY DATE PERMIT/SERVICE REQUEST INVOICE <br /> C-57 ✓WL -WA ER_ C-57 Letter of Authorization to sign permit_Encroach <br /> men <br /> t <br /> doc <br /> END 29-02-OOI <br /> 6!22/04 <br />