Laserfiche WebLink
• MENT <br /> Rk�EIVED <br /> 00. ':::�q San Joaquin County <br /> Environmental Health Department MAY 0 5 2006 SITE <br /> 304 East Weber Avenue, 3rd Floor,Stockton,CA 9520AryN J�DAQUIN GO <br /> HEALTH <br /> (209)468-3449 Fax: (209)468-3433 Web: wwwsjgov.org/C IRONMENTAL <br /> HEALTH DEPARTMENT UNIT IV <br /> Well Permit Application !! / <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED L- 57 S O Z 3 3`-I <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 /> o, pu went n��} c Assessors <br /> WELLLocation Cross Street ♦•(i`T_City -TrC-ci Zip SS•:j?7( Parcel# 14 <br /> PROPERTY <br /> Owner S v\, ccw������CixAr-IAA Address I610 CC,t,; NCizelk- 1lin-City-Si- -kyK'N Zip'?520Phone# Lzrte' <br /> C57 Contractor RcsCK-,c%,y\-5Lnn�C- Address 2 z o L ELCityV. c( Zip�57NF Llc# Phone# 53\0 lrin -2y2-tj- <br /> nsu t/Sub CntrC• fIA Co CS Address \\O <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,JPNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> MTNELL# t7UJ- k 0 PRESSURE GROUT <br /> 0'Other GROUT SPECIFICATIONS <br /> COMMENTS: SCB 0,7 1 eA VvayA�­\ (`� OL <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS See Ct7QCt`WC4 C6--y-V PLcctitS <br /> A M NI,TORIN 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS MULTI-LEVEL WELL CASING DW: _ <br /> �0�n'1T M <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL Q PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: BADGERS 0 HOSE <br /> 0 AIR SPARGE?OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes d No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: R OTHER APPROX, BORING DEPTH Ii BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications In comment section) <br /> COMMENTS: C CeC \ACV�(:�. 1_o`x�� �\G>'� C�C`z'FS-C' �o'\�Y-f'��i 5 \ a�X1C,��Ca4� Q*` 1.a.YV1 t" Zc.F� ,�-�� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 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 Title/Company2 � <br /> Print Name �ft _ Date <br /> DEPARTMENT USE ONLY SJw Com«slf» e <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Flhry 7t3"�cisS37 "� //'�U°6 <br /> WORK PLAN DATED: <br /> Application Accepted By Aell/ / `� ��• ' Date Issued Area <br /> Grout Inspection 8y Date Final Inspection By Dale <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECID BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Jr 7 e' !J/�33G SR# 0o 4f to 6$U <br /> 7S� 3 'b79:`° <br /> C-57_ WC•„=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />