Laserfiche WebLink
t San Joaquin Cbanty Ir �frdt�s� /'v <br /> Environmental Health Department SITE <br /> rx 304 East Weber Avenue, 3rd Floor, Stockton, CA 9520iri2 0ZnT MITIGATION <br /> . (209)468-3449 Fax: (209)468-3433 Web: www.sjgo`.:Q, �l�d <br /> , (sw,�,1,T0 r ` UNIT IV <br /> Well Permit Application PER,,417/,S'ERVCES <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 Environmental Health Department. <br /> Assessors <br /> WELL Location yy/ FrGn ab. C.-*",0 Rd, Cross Street t-PriC54 Rd City Fre-nC4 4,,^PZip ?5,711 Parcel#/93 •/ <br /> PROPERTY p 5.n <br /> Own erP Po.r- �'rc, Cit_c 41CAddress 77 SU/�� 544. City Are.#4 cf!reo Zip9H/.2G Phone#6/i3)T7.?-lagy <br /> C-57 Contractord bri/ ins AddresssAD �ivGrA/1aac� CitytQrvyif�Zif�fH57ILic#7�Ov Phone#�7o7)37y-�/3A0 <br /> Consultant/Sub Cntr SBGOR2 Address5'7 1wP4r je0g*_City Lic#1I5, Hq31 Phone.? ?gq_93ao <br /> GIS Coordinates:X Y Township 715 Range kogE Section Lf <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> (SOIL BORING# SB 1 0 OVER-BORE. DIAMETER <br /> )(WELL# t`fAj-1 - w 3 0 PRESSURE GROUT <br /> 0"Other GROUT SPECIFICAT NS <br /> COMMENTS: v / r .� fo�3 �•to ri <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING OHOLLOWSTEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SD4• qo TYPE OF CASING: 0 STEEL , PVC 0 OTHER; <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL —,27 1 TREMIE TYPE TO BE USED: ,{AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: %Yes 0 No (NOTE: MAXIMUM FREE-FALL (DEPTH IS 30') <br /> J'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 40UI&n6rd .�JCKi/o«i apt�� 7��o.nd CEµ+est <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH �r� BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby c hat I have pared this application and that the work will be done in accordance with San Joaquin <br /> Cou =e�Rg�ndR lations, and all applicable California State Lawns. �—yr <br /> Signed x Title/CompanyT1r1 Aco(� �Ge�O�j 1,}•� Scrc V _ <br /> Print Name W Date02 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: •Z Q <br /> Application Accepted By Date Issued - Area �6 <br /> Grout Inspection By Date / F nal Inspection By J <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> Z�o MVS • 2 5(0 LACU,,. SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc MA <br /> EHD 29-02-001 <br /> 6/22/04 <br />