Laserfiche WebLink
AMENT <br /> RSC F_IVED <br /> San Joaquin County <br /> Environmental Health Department MAY 0 5 2006 SITE <br /> 304 East Weber Avenue, 3rd Floor,Stockton,CA 95202ry�� <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.orreUIRONME AQUIN COUNTMITIGATION <br /> AMI UNIT IV <br /> HEALTH DEPARTMENT UNIT <br /> Well Permit Application r <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C- 57 6 Q Z J 34 <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 /> Ll� pcv'jo - er'i rye y:.} -t-r, I Assessors <br /> WELL Location \�,--r;W �ncc,m terr..A YIGA Cross StreetCity -Y C,1- Zip �SLj7lo Parcel# <br /> PROPERTY <br /> Owner CU\��tAddress 1810 (KS} NCfl2l' Cityrlr_Gi�--f"Dn Zip r1.`Zr? Phone# c` ' <br /> C-57 Contractor_ C+Y.�r�-St��C- Acidness 220[ FCl_�{' `i} CilyV.i a ZIpcM1571(d Lic# Phone# 53\b Ictnr -2y2-L{- <br /> nsu t/Sub Cntr(�' �n\ Z r VV,\Q5 Address \\11\ -}W\ 54pan-l- City3lJ�Lid* Phone#(2 27.-r}{(� <br /> GIs Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ONEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> g SOIL BORING# a OVER-BORE. DIAMETER <br /> QUELL# DVJ- 1 a PRESSURE GROUT <br /> g`Other GROUT SPECIFICATIONS <br /> COMMENTS: —'-ez <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS -C et C, ,-twIC/'l�C.� <br /> MOt91TORING &))(]HOLLOW STEM DIA.OF BOREHOLE_ d MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: _ <br /> g EXTRACTION 8 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: p STEEL g PVC g OTHER: <br /> Q VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: BADGERS g HOSE <br /> g AIR SPARGE/OZONE g PUSH POINT(GP or CPT)GROLIT SEAL PUMPED: a Yes g No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> g OTHER: a OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or g STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (If YES,list specifications in comment section) <br /> COMMENTS: P ox\\QCT' A L67i 1(- <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 Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x -- A� Title/Company ,-J,� <br /> Print Name �i. GG Date <br /> DEPARTMENT USE ONLY 5 fwfr Com«of e <br /> SITE MAP IN UNIT IV FILE, ADDRESS: RI`z1`713 "t�p 1 SS3 j I-) � /�10114re6 <br /> WORK PLAN DATED: ��/ <br /> Application Accepted By �Gtl T/'"�'P< �' Date Issued �' *' Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 753 X279'°` U/8336 SR# DD 4�G6$J <br /> C-57— W--WAIVER.– C-57 Letter of Authorization to sign permit_Encroachment clot_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />