Laserfiche WebLink
0 <br /> SAN JOAQUIN COUNTY FILE COPY <br /> K � �� ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> F1E 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telep one: (209) 468-3454 Fax.: (209) 468-3433 Web: www.sigov.org/ehd UNIT IV <br /> d 3 4. 010 <br /> rr0�pA WELL PERMIT APPLICATION C) fl S ITE <br /> ENVIRONMENT HGrfN_REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ) <br /> PERMIT/SERVI' E0i. <br /> Application is hereby matte 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 /> I'I <br /> {p , W 2111 w /� � �VC•� Assessor' <br /> L� <br /> WeIIation . _ _ toss Street Ff°..k\: -. JQ City S}ee.IC� Zip Parcel # RVUj <br /> Property M S�nrk}sn <br /> Owner�i�0Ae% f0•I^'1••' Address 1`610 E . Vj,%t TFon AW, City Zip `1Suq Phone # 24MM68 , )CYr � <br /> C-57 Contractor Eat�,4 Address 23 3 z orrr[c C.N1:1. - City 2G•'elai CorAAkZip Lic # q16.61Y.Il6q Phone <br /> ConsultanUSub Cntr �^AP-cA=K Address. 1930 6k4•1 DnNA S 41WClty , F / <br /> • IJ ° Lic # Phone 96. IrS, 2029 <br /> GIS Coordinates: X ✓ 1 • l�' , Y 124a 321 Township Range Section <br /> WORK TO BE PERFORMED: <br /> ',kNEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER•) ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br /> ❑ SOIL BORING# ❑ OVER-BORE DIAMETER <br /> [K WELL # ML.J1 ) B .An.l My - 14R �•lvo job..\> El PRESSURE GROUT <br /> El *OTHER GROUT SPECIFICATIONS <br /> ❑ EXPLOSIVES DETONATING CARD - <br /> COMMENTS- ,TA0-0,164 oP 4-Li n,"4: t^Kflt S�+'� ac l '�° - wN u `I ° -I. So •69 14 <br /> G.+.luciar CnSt..F he af� eax . 3Sr 64b 4u w. : � :•�, 7r.e At + it for cr•rj c...la�+•+si,b. 4#h*&d. <br /> TYPE OF WELL INSTALLATION TYPE • CONSTRUCTION SPECIFICATIONS r[ A f. eAc , <br /> 'i� MONITORING A HOLLOW STEM DIA. OF BOREHOLE, tS- 63MULTIPLE CASINGS D MULTI-LEVEL WELLCASING DIA: z M <br /> ❑ EXTRACTION El AIR HAMMER/DRIVEN CASING THICKNESS rr TYPE OF CASING: 0 STEEL A PVC ❑ OTHER <br /> El VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEAL '� 3s� I - TREMIE TYPE TO BE USED Iq AUGERS 0 HOSE <br /> • on,. pIp` ?• S•s4 <br /> ElAIR SPARGE/OZONE LI PUSH POINT (GP OR CPT) GROUT SEAL PUMPED: p'ves ❑ No (NOTE: MAXIMUM FREE-FALL <br /> DEPTH IS 301) ,� P�✓S <br /> El SOIL BORING - ❑ HAND AUGER GROUT SPECIFICATIONS 2- - .07 c°�1"+ <br /> 0 OTHER: ❑ OTHER: APPROX. BORING DEPTH A' S D 1d BOLTED TRAFFIC BOX OR ❑ STOVE <br /> CONDUCTOR CASING PROPOSED yl:S (ir YES, r}st specifications in co tseaion) <br /> COMMENTS: b6�k LAICWC Ul I1 1. .K o.,Jer• S�tf-1 �nne( O I oy_*Q• �e ,'bgs . e,F qt( <br /> ✓:It be .S�.Iea wilt. wfwq- Ct. 1�.r rood._ 9 cs+f,• +- qra -}� Surat arss.�, <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENOACHMEN PE ITS <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 I accordance with San Joaquin County Ordinances, Rules and (� <br /> Regulations, and a able California Laws. �r\q <br /> Signed Title/Company Q.'t +'h) zo& er42L,S <br /> Print Name Date r-/4 //o <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORKPLAN DATED: <br /> APPLICATION ACCEPTEDB; q �� d AREA O/� re <br /> GROUT INSPECTION BY CCS I I P'IC: 15 tbb 40 SPECTION BY DATE <br /> DESTRUCTION INSPECTION BY ATE <br /> COMMENTS/CONDITIONS: - <br /> ACCOUNTING ONLY: AID #- FAC # <br /> PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DAT PERMITISERVICE # INVOICE <br /> 35o M 4sR• D �fo �Ol 5 i3 �oJeSIR#423 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCJZOACHMENT DOG <br /> EHD 29-01 10128/09 �-/VCELRMAPP <br /> FILE COPY <br />