Laserfiche WebLink
San Joaquin County <br /> Environmental Health Department SITE <br /> 1 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209) 468-3449 Fax (209)468-3433 Web www sjgov org/ehd UNIT IV <br /> PEP Well Permit Application <br /> ' NON-REFUNDABLE PERMIT EXPIRES 4 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 /> WELLLocation 1810 f 1 q-Lel#on Ave Cross Street + Stott# City 51licKt0s7 Zip <br /> 95205 Parcel# 155- 1?0 -47 <br /> PROPERTY <br /> °Owner ,TOq 6(%4 CO3A03 Address till t+Scr,% Ave City_ f6t:Kto4 Zips 0Phone# 0001# 0- 9625 <br /> 1 C-57 Contractor Address City Zip Lic# Phone# <br /> 74SVP4 94b4ollt? 0 gox 869 <br /> Consultant I Sub Cntr Rg!ng f E KV,I h t:. Address k c w Y+,@i4 City 95 b 8 3- Lic# R Fr 57 S 6 Phone# (916)3 54 32 5 0 <br /> ' f , GIS Coordinates X Y Township Range Section <br /> WORK TO 8E PERFORMED <br /> NEW WELL I BORING (CPT GEOPROBE HYDROPUNCH HAND-AUGER OTHER") D DESTRUCTION (choose type below) <br /> r 0 SOIL BORING# a OVER BORE DIAMETER <br /> {II /WELL# 5YE-i /g c S-1 SVE-1113= rAw--f 0 PRESSURE GROUT <br /> Q'Other GROUT SPECIFICATIONS <br /> COMMENTS -- <br /> TYPE OF WELL INSTALLATION TYPE !PQNSTRUCTIONCIFIQATIONS - SEE WELE %jIA5TKVCjt0fj QlAtrkAM5 - 411ALKE4 <br /> a MONITORING HOLLOW STEM DIA OF BOREHOLE, Q MULTIPLE CASINGS (]MULTI LEVEL WELL CASING DIA ______ <br /> .' �XIITRACTION AIR HAMMER/DRIVEN CASING THICKNESS A 114 40 TYPE OF CASING (]STEEL I PVC p OTHER <br /> F, 4POR d MUD ROTARY DEPTH OF GROUT SEAL * TREMIE TYPE TO BE USED S AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE ❑PUSH POINT (GP or CPT)GROUT SEAL PUMPED p Yes I No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> ! p SOIL 80RING (]HAND AUGER GROUT SPECIFICATIONS NEAT E E M E WT <br /> J OTHER NtSTED 0 OTHER APPROX BORING DEPTH * I BOLTED TRAFFIC BOX or p STOVE PIPE <br /> N1vm-VS E CONDUCTOR CASING PROPOSED H 0 (of YES list specifications in comment section) <br /> COMMENTS <br /> f5 NOTE. OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> i <br /> ! hereby certify that I have prepared this application and that the work well be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws <br /> Signed x TalelCompany (,c N 5�►tA}i T R A M A tY� E t�V j N t, _ <br /> Print Name J 0 5 E tP H R A M IVG E Date Z 5 <br /> ' DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT 1V FILE,ADDRESS <br /> WORK PLAN DATED' <br />' f <br /> Application Accepted By Dale Issued Area <br /> i <br /> Grout Inspection eDale Final Inspection By Dale <br /> y <br /> Desinrction Inspection By Date <br /> COMMENTS I CONDITIONS 0111111 <br /> . ECOUNTING ONLY AID# FAC# <br />' FEE INFO AMOUNT REMITTED CHECK# REC D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# <br />' I C-57— WCC WAIVER— C-57 Letter of Authorizatton to sign permit—Encroachment doc <br /> L EHD2902001 <br /> 6122104 <br />