Laserfiche WebLink
n <br /> o .. San Joaquin County v � <br /> Environmental Health Department •�. (/ ITE <br /> " 304 East Weber Avenue, 3rd Floor, Stockton,CA 9 /p'"4 ri ® �Gf I ATION <br /> o (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.9j <br /> 4f, ?�0 <br /> LThpyf ppR�` Well <br /> PERMITit 1plicationYEAR FROM DATE ISSUED <br /> fry 190' T <br /> NON-REFUNDABLES <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. <br /> L, Assessors <br /> WELL Location 'DC7 ross Street r Cityyc c-_L _-'%Zip"1 S 2-- ,-Parcel# I�,5 C--A U•i�., <br /> PROPERTY5c\c -BSc <br /> Owner :.' `fir S�'• nl Address Fr.-¢. City ip r'.'�'-�IPhone# <br /> ��•� `Is-) ic# ," Phone# \i le. -55 illi <br /> C-57 Contractor C<.<:r c vac',\C..-<;Address-1( - .S O,Yac- c',r--�Clty :ar <br /> c <i:�.r.Zip <br /> c,A t A <br /> Consultant/Sub Cntr ddress City Lic# Phone# wi\: - 8wA • <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 /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> SWELL# v . t„,r,_,.^, p PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: MW 1-kA <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> fYMONITORING "OLLOW STEM DIA.OF BOREHOLE ''y' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_ <br /> O EXTRACTION <br /> 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:KTEEL 0 PVC 0 OTHER; <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AAUGERS p HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: B OTHER APPROX.BORING DEPTHi. >F' G' OBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED -tip \ (if YES,list specifications in comment section) <br /> COMMENTS: <br /> v=;r\\ �+.,.. do,,..33`n_. c-t•.S�d u".�.•...5 1S "1i' c�.s cst� c-l.c\ X° cvu� i �v..re.�c:iu'l�c� '."3.5: �c+.�i cwt'`. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS.«F <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 /> Signedx ;r�—,� 4^C�v�z,ri Title/Company cr- 4YySCicviS!- <br /> J <br /> Print Name Date l cA Z.`1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 5-QR Wes+ Ch ar+e-r W4y <br /> WORK PLAN DATED: <br /> 1/ / 001;;4 l2, ZQQd 7 - <br /> Application Accepted By Y j<lT/iy.) - `' !/Lt-44-"Z�e4 Date Issued 6 ikQ� 20o%rea <br /> Grout Inspection By-li d9Ni 4 Mt&n6&!4_Date 1-1q&'If Final Inspection ByDate t-.25--08 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# 17 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 350 / 89.00 '�9. �� 02 3 719 /0.3/-07 SR# 00SZ41 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6722/04 <br />