Laserfiche WebLink
M'� G <br /> COPY <br /> a� San Joaquin County <br /> q � II <br /> �i Environmental Health Department PR �p� SITE <br /> 304 Fast Weber Avenue, 3rd Floor, Stockton, CA 95202 M o�N�'llIT1GATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ �OAa �v4N �- <br /> z, o+x ` G �,vk�0""' � eW UNIT IV <br /> Well Permit Application !I VVENov° <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 9-1115:3 and the Standards of San Joaquin County En%nronmental Health Department. <br /> 7 k! `` � k Assessors <br /> WELL Location 39 f� Ec rm-n -6r, Cross Street w 9 5 City S+oc.k4on Zip 5 05 Parcel# <br /> PROPERTY <br /> Owner .cK P,4C I _iAddress 3LJl` City__S* !i Zip gs-'10SPhone# 9(04/-300I ll <br /> C-57 Contractor4rlViP o1102 Address '? City StK�1 Zip%,�J1S Lic#49=-? Phone# 4(07-100(, <br /> �i <br /> Consultant/Sub CntrA n c ej neo Address$3 7 Sl�c.,.+ City S i"k Lic# LQ�_7 Phone#4�7-!00 L <br /> GIS Coordinates:X 'Y Township `I Range Section ' <br /> I <br /> WORK TO 8E PERFORMED: ti I <br /> %NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) J'J Q DESTRUCTION (choose type below) <br /> DeSOIL BORING#.S a-I i'Nrouq� S(3:S ) Q OVER-BORE. DIAMETER <br /> WELL# i Q PRESSURE GROUT <br /> Q"Other GROUT SPECIFICATIONS <br /> COMMENTS: .1 Se �s, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Il <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLEI•.S" Q MULTIPLE;CASINGS Q MULTI-LEVEL WELL CASING DIA: 44 <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS N-4 TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEALW 4W-"A { TREMIE TYPE TO BE USED: Q AUGERS flHOSE <br /> Q AIR SPARGE!OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes �Wo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> *$OIL BORING Q HAND AUGER GROUT SPECIFICATIONS ?01r+1a C GMel+- <br /> Q OTHER: Q OTHER APPROX.BORING DEPTd) 1' t U-�7' Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (%j A (if YES,list specifications in comment section) <br /> COMMENTS: l' <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I herebyMcertifNyI have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ruan tions,and all applicable California5fate Laws./�SignedxTitle/Company2n� Cdr- A�� <br /> Print Nam Ck l.$-�dA, its lle,- it Date 3' x005 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: _')q I G 0/ V <br /> WORK PLAN DATED: D j <br /> Application Accepted By Date Issuedti, `� 1 'O 5 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date i <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# { <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK# REC-D BY DATE , PERMIT P SERVICE REQUEST# INVOICE <br /> [1 /-701 1 3095 <br /> C-57�:7 -WAIVER_ C-57 Letter of Authorization to sign permit ncroachment dac/t/ <br /> EHD 29-02-001 <br /> 6/22104 I <br />