Laserfiche WebLink
t San Joaquin Couno <br /> Environmental Health Departme ���`�L� �ITE <br /> a - <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 UTICATION <br /> (209)468-3449 Fax:(209)468-3433 Web: www.Sjgov.or # <br /> 1 20015 UNIT IV <br /> ' Well Permit Application F.n:'� ri0,k,,ke��� <br /> NON-REFUNDABLE PERW EXPIRES 4'1 EM FkOM DATE <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 Tine,Chapter 9-9115.3 and the Standards of San Joaquin County Environmental Health Department, <br /> k' Asse"Ors <br /> WELL Location � Cross Street_ " City Zip 5,5Pamla <br /> PROPER C ob ��-- - Sfy*ki- <br /> Owner y Address City� .� 1Zlp Phoned -- -- - — <br /> trS7 Conti-actorZ3 111�� Address.gSoV�-( City !!- e � <br /> ZApLIc*y455I V Phone*IC s 31 3_-Sg o0 <br /> Consultant/subCntr�`1PcO�±Cfc 1 jg.h Address�li�l ��"' City t S c;� — kp l�honet� a 2� . �(.((c( <br /> GIS Coordinates:X Y_ Township - k Range Section <br /> MRK TO OF e9RE itIVIP.D:. r <br /> Q NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,BAND-AUGER,OTHER'') STRUCTION 1 (choose type below) <br /> aSOIL BORING# VER-BORE.-DIAMETER <br /> u WELL#� a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> , <br /> COMMENTS: <br /> TYPE OF WELL JUSTAL!AD20 TYPE CONSIU=gN SPECIFICATIONS <br /> ,,J311ONITORING lI HOLLOW STEM DIA.OF BOREHOLE- 0 MULTIPLE CASINGS d MULTI-LEVEL WELL CASING D A:'� _ <br /> Q EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 1]STEEL; PVC u OTHER. <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> Q AIR SPARGE/OZONE q PUSH POINT(GP ar CPT)GROUT SEAL PUMPED: II Yes a No (NOTE:MAXIMUM FREE�FALL DEPTH IS: 30') <br /> a SOIL BORING a HAND AUGER GROUT SPE:CfF1eATI0NS '" <br /> a OTHER: R OTHERS APPROXI BORING DEPTH' 1 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPO,SED (if YES,rst specdcations In comment section) <br /> COMMENTS: <br /> NOTE OFFSITE BORINGS REQUIRE ACCESS AGReEMENT OR ENCRQAGHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS.." <br /> is r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin <br /> County Ordjnqp at€ons,and all applicable California State Laws.. <br /> Signed x T'iNe/Comp' <br /> Print Nam l Data 4' <br /> DEPARTMENT USt ONLY <br /> SITE MAP IN UNIT"IV FILE,ADDRESS: <br /> WORK PLAN DATED: of <br /> 11 : <br /> Application Accepted By i Date IssuedPori, �"O r <br /> A 1,. <br /> Grout inspection ey Date Final Inspection ByAl <br /> ate <br /> Destruction Inspection By A ADate <br /> t; <br /> COMMENTS I CONDITIONS:- I444 A <br /> ACCOUNTING ONLY: AtD# FAC. I�fa I i <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK tk R5CID BY; DA PERMIT!SERVICE RSQUI_ST# INVOICE <br /> 3S'o Z d - pIJ zz sR# ( 64b Z <br /> C-57 Wt:_:_„,---WAIVER,— C-52'Letter of Autho ora o sign pertnit— Encroachrnent do'c <br /> F—RD 2M24101 <br /> 6t22ro4 <br />