Laserfiche WebLink
' • San Joaquin County • COPY <br /> ' Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/elxl t ' A011UNIT IV`4 � - - <br /> Well Permit Application / ' A <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ^ —r— f/ <br /> 0 " <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 Sari <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health pDepartment. <br /> Assessors <br /> WELL Location 19366 W. Nrill 44e 12d Cross Street hf#&d ie City T/�4e-u� �zip 15'39/ Parcel# 2.09-' Dia- <br /> ' PROPERTY C1 ty Tracy Zip�Phone* <br /> ownarC6arles fs Ma*r9l n TltsnAddreas 17�pY4 S. IaMmars . Tracy -r� <br /> C-57ConlractoryIW DrljtInr� [qG Address P-0- PDX �'�/b /Cii il..Zip.?S'W/Lic#7zol4hone#(9/41)777—Y16O <br /> ' Consultant/Sub Cntr0d11000—K"AIs ASS°GAddress3gla k). AA1040,114%Ciy 1 o Lic# Phone#(U9)2-3y-772-1- <br /> GIS Coordinates:X TgA Y Township C s Range f E Section /6 <br /> ' WORK TO BE PERFORMED: <br /> )'NEW WEL /BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOL <br /> OBORING# 0 OVER-BORE. DIAMETER <br /> 0 PRESSURE GROUT <br /> ' ther GROUT SPECIFICATIONS <br /> COMM TS: <br /> L INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ' NITORING HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Aftp TRACTION p AIR HAMMER/DRIVEN CASING THICKNESS L 4 1{O TYPE OF CASING: p STEEL )IyVC a OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 4 6 r TREMIE TYPE TO BE USED: -AUGERS 0 HOSE <br /> ' 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 1]SOIL BORING aHAND AUGER GROUT SPECIFICATIONS nEaf GEMQnf <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH ,S 0 BOLTED TRAFFIC BOX orTOVE PIPE <br /> ' CONDUCTOR CASING PROPOSED n(0 (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 certify that I 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/Company rr°_ J• 4eCC IS' ' <br /> Print Name Fred lti/. 64,ts Date ANgv1 5 a6 2ooS <br /> ' DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ld SL-)Z> t1�v Fel - ilaLn br <br /> WORK PLAN DATED: -Z'oL J <br /> ' Application Accepted By Date Issued / 6 ��r Area 6 60 <br /> Grout Inspection By Data Final Inspection By Date <br /> ' Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> ' 290136aoy/ �' SR# ©© 958 <br /> C-57 WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encr ment clot_ / B- <br /> END 29-02-001 <br /> 6/22/04 0 <br />