Laserfiche WebLink
C <br /> op "'• .� :an Joaquin County FELECOPY <br /> _ <br /> z� Environmental Healthhhhhhhh partment I»4�(2� Elil1 / _ !$ITE <br /> " { 600 East Main Street, St- Aton,ZA 9#�2-3029 MITIGATION <br /> ` (209)468-3449 Fax: (209)468- www.sjgd�. *lehd APP 0, 0 2008UNIT IV <br /> P <br /> Q`,�oRN Well Permit Application <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 C u ty Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> L � <br /> TDt - ! Assessor <br /> WELL Loca on _ d��d ' O� ross Street City •!t" ? Zip �S Parcel# Xlj` <br /> PROPER / ` !/gyp <br /> Owner b __'VIA-1 addressl0 10 G- City- Zi J��S rnone# 7`G�0s7 <br /> «< �Z.S/ <br /> C-57 Contractor !�s 1�K'/L( l y1/E� —Address 22G N��.//���Si S r City tir�d�/,V2�Zip`?�74Lic# �33'� Phone#5��' r` '2 q 2�`� <br /> Consultant/Sub Cntr cJ�`�� Addres '�t(J W�fi��� SJ7i�o�Gy Lic# Phone#-7/'6' ��' 07/57 <br /> GIS Coordinates:X37-7-52-- Y-11,21 .YFL Township 021-5 Range r4 E Section f3 <br /> WORK TO BE PERFORMED: <br /> VIEW7WLL/ BORING (CP GEOPR J YDROPUNC�l HAND-,AUGER,OTHER-) 'AQESTRUCTION (choose type below) <br /> / OIL BORING# Sl}31 �, U L <S -20 ESp_g, £ Sd_/ p VER-BORE. DIAMETER <br /> ELL# ZRESSURE GROUT <br /> a`Other GROUT SPECIFICATIONS <br /> COMMENTS:_ LW l <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE. .49 oMULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: 0/14 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 0/14 TYfPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1s 75' TREMIE TYPE TO BE USED: 0 AUGERS OSE <br /> 0 AIR SPARGE/OZONE IOUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes o (/NOOT,E�::M�A-XXI+MUM FREE-FALL DEPTH IS 30') <br /> OIL BORING �1 0 HAND AUGER GROUT SPECIFICATIONS 6F 1( -4-- <br /> QTHER: FV J 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> INS CONDUCTOR CASING PROPOSED MIA (if YES,list specifications in comment section) <br /> COMMENTS: LIOU?A/ 1i BVr-4N6S 4jiLL (-IW- TPMPvI?l�V-YWIit.I 'MATr' S CJN.SmvcT10 Uy- A 012FP/tgr () T(uji-Ei4?, <br /> SCP-C-0N AW yvC c as 1IV01_ <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 repared this application and that the work will be done in accordance with San Joaquin <br /> CountyOrdirl ces, Rules nd Reg tions, and all applicable California State Laws. -� rz-t <br /> x Title/Company ( C rJI�U�Mef-xZ-��N�t"�o1 hkic— <br /> Signed <br /> Print Name J` t,V 1-r Date <br /> DEPARTMENT USE ONLY e Zq�a <br /> SITE MAP IN UNIT IV FILE, ADDR S: /��Zy <br /> WORK PLAN DATED: D,6 <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By ate Final Inspection By L I �' r" ate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED 9"EC1C# IS REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ?tea l / OSq lSR# <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 WEB V*14-5• 0 4 l/l3 L 9 <br /> 9/11/2007 r <br />