Laserfiche WebLink
QAu San Joaquin County <br /> D) <br /> l� !I Environmental Health DepartmentR �✓,/ SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> MITIGATION <br /> r (209) 468-3449 Fax: (209) 468 -3433 Web: www.sjgov.org/cjTV 0 8 2004 UNIT IV <br /> Well Permit Application ENVIRONMENT HE <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEPDERVIIT/SERVICES <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 /> WELL Location 1 - X � r .�-� uTt'L�f71, 19.41 ross Street (19-�''r cit �Slocg y. ` e" Assessors <br /> Y - Zip I� Parcel# <br /> PROPERTY - <br /> Owner � ''� I' ala Address 05 N E /GO( o 8 �� q q �. cp �l <br /> �t r- `...L�b� iCity lCiiP tom% " Phone# 'Zo { _, l � 1 C) <br /> C-57 Contractor I`tS A� Address ,� "� 00 GCLf' ( -�`i Cit tr� C�e�� "' � � fh <br /> _ Y ip i"7 Lic# U Pho e# � <br /> Consultant / Sub Cntr_I h1e_(L `Iay2 j ci. 'v:) Address 555 (TJ77 p/(((,LCI City W1 ,c# 'Gd7 <br /> J Phone# iL <br /> GIS Coordinates : X , Y , Township Range.9 Section <br /> WORK TO BE PERFORMED --� _ <br /> 0 NEW WELL I BORING (CPP E� OPR BE, HYDROPUN H, HAND-AUGER , OTHER' <br /> ;&SOIL BORING # _ 0 Iv`Oy ;;5�d -.}- O Q 4.4?1 ) 0 DESTRUCTION (choose type below) <br /> DWELL # DOVER-BORE. DIAMETER <br /> 0 *Other rRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> �i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL <br /> 0 PVC p OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEALS s TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/ OZONE PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> p OTHER:.fl OTHER APPROX. BORING DEPTH r] 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS , <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I havepre ared this application and that the work will be done in accordance with San Joaquin <br /> County OrdinancQS. RytTes d R ulations, and all applicable California State Laws. <br /> 1/ l/ _ <br /> Signed x .� � <br /> Print Name <br /> � Titie/Company. 1(�/1Ck (�i KY <br /> / > ) <br /> ✓ �-, . . � � -� � Date <br /> DEPARTMENT USE ONLY L <br /> SITE MAP IN UNIT IV FILE, ADDRESS : / 3 a /V o Y FSI I IJn I P Y SfY ce <br /> WORK PLAN DATED`: , 2) (2 C d �e y ! 0 Zp a 4 — <br /> Application Accepted By \/ I G +A r i CI y yt C eyr-1-�.t 2C7 Date Issued Irl PC wry [��� 3 Zf- 0( rea_� <br /> Grout Inspection By j yy. 1 R i /h r+M _ Date ZW -0 Final Inspection By ff Date 7 <br /> Destruction Inspection By '-- — l��" <br /> Date <br /> COMMENTS / CONDITIONS : S in <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEEINFO AMOUNT REMITTED CHECK # RECD BY DATE TPERMITISEP\ I . - REQUEST # INVOICE3sa89. o� 89, 19 ( 664D <br /> C-57_ WC.-WAIVER. C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> EHD 29-02-001 <br /> 6122/04 <br />