Laserfiche WebLink
San Joaquin County <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/ehd UNIT IV s <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EMRE8 f YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or Instal{the work described. This application is made in compliance San <br /> Joaquin County De <br /> lvelopment Tltle,Chapter 11`1115.3 and the Standards of San Joaquin County Environmental Health Department. ason6 Z-7�Vo-v5 <br /> WELL Location 25DD W, Lodi A4. -_crow Sttreet c�'fn city �.Or�i zip ��f� rc/� <br /> PROPERTY /,(� ! 6 Y O Z �DD'G7 <br /> owner kj_j5 Nt LV Snf Address��0 Z+x G City Fwr 85 zip 9 L-' phor,ee I � 7 ?2y <br /> C-57 Contrastor� [ Nxin4 Aldfdmss 550 R� Cly i4 (I Zip LIo:R� Phones 707-32-48)o <br /> ConsuldlrrtlSub CnlrclPS �rl�irsxr+K, AddressO lr{MtPNrikQ.Clty�� /A1��9�(id'r Phona;lt,f�-ZpLZ <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELLI BORING (CPT,GEOPROBE.HYDROPUNCH,HANO-AUGER,OTHER*) DESTRUCTION (choose type below) <br /> a SOIL BORIN 8 OVER-BORE. DIAMETER <br /> p `WRESSUREGROUT1 t <br /> O'Otlnar GROUT SPECIFICATIONS_neWfC GvT1 <br /> - <br /> COMMENTS: /k-w l�raa d127� F�- �.�_ 2,060 <br /> TYPE OFV INOTALLATION TYPE COMM"ON SPECIFIC MONS (ke QAWt'-r't A171C' <br /> WNiTORING 'HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS a MULTI- L WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL p PVC p OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> `(AIR SPARGE!OZONE 0 PUSH POINT(GP or CP1)GROUT SEAL PUMPED:" Yes No (N TE: MAXIMUM FREE-FALL.DEPTH IS 301 <br /> Q SOIL BORING 0 RAND AUGER GROUT SPECIFICATIONS_-Af <br /> 0 OTHER: P OTHER APPROX,BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE , <br /> CONDUCTOR CASING PROPOSED (if YES,list speeiflca ons In comment section) n <br /> COMMENTS: GI AW-2; 1 "I W- —Z µ4J6,1—-I; <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby co"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 /> J7lM 1 <br /> Signed x t"� TllldCompany toco(A5i S f'^ ST �yi roto est/ � C, <br /> Print Name Sre4 gr+�w'- Date f <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FIL ,ADDRESS: <br /> WORK PLAN DATED: �f-ZZ- <br /> Application Acoapted RyAtl 4-' Date Issued ZI-3 /a Y Area z_ <br /> Grout Inspection By Date Final Inspection By Date <br /> Destiuction Inspection By Date l <br /> commTs I comrnoNs: At W-7 4AL w <br /> ACCOUNTING ONLY: AID# '9 <br /> FACa <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK/ REC'D BY DATE PERMIT!SERVICE REQUEST* INVOICE 1 <br /> HOZ (ab` 66" 77 V3 bft— ! 3 D SR#005`6 7- <br /> C-57 WC -WArVER_ C-57 Letter of Authorization to sign permit_Encroachment doc ' <br /> EHD 29-02.001 <br /> 6122104 <br />