Laserfiche WebLink
yl. <br /> r E COPY <br /> ,o,.?•r ca San Joaquin County <br /> y ` � O,ZUU6 Environmental Health Department SITE <br /> r „ I <br /> e68ast Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> -3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> arc n , IVII1f5k� <br /> 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 <br /> Title,Chapter�9-1115.3 11, ,and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location �PT�Z7 664,7n ( 7�Cropss Stre�eytW It S aty ro, zip 53 Panel#Assessor2a2-O�o- oy <br /> PROPEC—"'/ // �. ddress �OZ/ ,/� { pyr <br /> Owner City_ —IZipft�Phone# <br /> C•57 Contractor �Yll Ad dress �. EASi'S"t" City��atlA�Z�p`1577�; °233`hone# 530 <br /> ' I ,ff A 9 Zit 2y <br /> Consultant/Sub Cntr SA L Address 3go0 or'l e'er-C.Ity S'�V0`^^�jc# Phone# / 971 -39co <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> .SOIL BORING# 1 0 OVER-BORE. DIAMETER <br /> WELL# <br /> 0.Other 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE % 0 MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS N/Ann TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ' 7 <br /> iQ +- TREMIE TYPE TO BE USED: �1CAUGERSov HOSE <br /> 0 AIR SPARGE/OZONE (PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> SOIL BORING U HAND AUGER GROUT SPECIFICATIONS / e-g4- P ej2j .rl-' <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 30 �aa'� 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED Al/A (if YES,list specifications in comment section) <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 Ordinan�e�, RWe�Regulations, and all applicable California StatteY Laws. q <br /> Signed x 11// S � Title/Company S5C7t�wg 4- <br /> Print Name Dan,L, kv)7_e.\01x Date /01 I2'06 <br /> DEPARTMENT USE ONLY,r, A <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Z6S01 3. Bm,r-�I.t CUP—w 0-C.p., Z9-to 6 <br /> WORK PLAN DATED: Zoe 6 <br /> Application Accepted By _ Date Issued 1- 6'-O 7 Area Ud 4) <br /> Grout Inspection By Date Final Inspection By Dale <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST* INVOICE <br /> ( gle M 87 4901mbao p 6 SR# C <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to Sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> OK <br /> 6/22/04 / <br />