Laserfiche WebLink
,a.•°U. o •an Joaquin County • <br /> ' Environmental Health Department SITE <br /> �1 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> i (209)468-3449 Fax: (209)468-3433 Web:w%,w.sjgov.org/ehd UNIT IV <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 Title,Chapter&1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location. I(oCC W r-LA rj Cross Street � '�)3_City rp YJL- Parcel# \1��-C�,A <br /> PROPERTY LIEDuN\L- <br /> lTvner ZP_t'nc C=1ri, Address\�c Vl:Zvi ur".• City �r(1G,_ _Zip CkS-�' PhoneC �2x'G ?a5 - <br /> C-57 Contractor 12C`a^A-Li-4. ]\"l\C Address 22-0 rJ EQSA ` Cityip 77 LIG€ Phone# �\'-l>>Icae� -zy2 c . <br /> onsu /Sub Cmr C.JLOkr W.\VCWn Cc, Address hQ mss', City Q �D Lic# — Phone#�ZC�,);=�zz -. y.ltoi <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,*NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) Q DESTRUCTION (choose type below) <br /> u SOIL BORING# a OVER-BORE. DIAMETER <br /> `3 O ELLLLr# 0 W-2 rn - 1 ° Q`'- 2- a PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: Sec at4CteVPn� tckr l; h\c�o� �r ark (t� 1�-�� s �ticrk Slav \AAdr nod y m #c��cL� \V- 7-C6 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r---Eke C"VF C4-CA <br /> '.V-Z,@:MONITORING )3 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> G EXTRACTION U AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL 0 PVC 0 OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> AIR SPARGE1 :Z a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: O Yes ONO (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> O SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> p OTHER: R OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 11 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (If YES,fist specifications In comment section) <br /> COMMENTS:_ SeE R\\cAcY\e�a 0��k Plt�v erste. S I, m- <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 Sart Joaquin <br /> County Ordinances,Rules and Regulations,and all applicable California State Laws. <br /> Signed z_ ��r't""Com <br /> pany <br /> Pin ame _.- bate 4` <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By 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#4;q <br /> SR# <br /> C-57_ WCC WAIVER,_„- C-57 Letter of Authorization to sign permit—Encroachment doe_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />