Laserfiche WebLink
1 <br /> • � i� U'Ih11 <br /> San Joaquin County ��,C,,, `L_F= <br /> Environmental Health Department SITE <br /> 600 East Main Street, Stockton,.CA `" 7 '�TIGATIONA 95202-3029 IY14'i t <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/kll ltiOi i\4'IVT HE-APPIT IV <br /> Well Permit Application �f PEPWIT/SEP' <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 County Development Title,Chapter 9-1115.3 and <br /> the Standards of San Joaquin County Environmental Health Department. sessors <br /> WELL Location — `^I �� (�at l� }1 Cross Street 1`G tAJ? City ()y-A,VZ�P �LI � P�tarcel# IS3 'Z 6`I`•11 <br /> Owner TiTI� I. 1� T�Address �� y", LG �\�F� City Q� ��Ut`� Zip 11513 02hone# iu f-"r'7 7 7 / J <br /> Owner I I /nt t `[1�. <br /> C-57 Contractor i/( C' 0�/ l;y Gb Address � � � N' CdY QV�I\�itCn.ZiP Lic#) Dt%t��Phonetaw �A <br /> Consultant l Sub Cntrl� ,i i. i�/.:,tS.�P�"`� Address-41-1, Lic# <br /> GIS Coordinates:X <br /> y.,Township Range Section <br /> WORK TO BE PERFORMED: DEST <br /> 7 NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p OVER UCTIRE. D (choose type below) <br /> 0 SOIL BORING# 3= 0 PRESSURE GROUT <br /> _ DWELL# _ _. _ - - GROUT SPECIFICATIONS---""---" - - <br /> U`Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE)!L�X10 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS AA TYPE OF CASING: p STEEL D PVC 0 OTHER: <br /> VAPOR MUD ROTARY DEPTH OF GROUT SEAL I', L d) TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: QYes Oo (NOTE;MAXIMUM M FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS E\ l ( <br /> g OTHER—0 OTHER APPROX.BORING DEPTH—D BOLTED TRAFFIC BOX or g STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 Or inanceS, Rules and Regulations, and all applicable California State(Laws. / n 1 <br /> Title/Company S�G>�'S �Tt_1�G� s) Al f, 1'�SSh�i(h1'QS <br /> Signed x `' 'y 97 v <br /> Print Name <br /> Q �-br V� 11� Date / ..A ' f71, <br /> DEPARTMENT USE ONLY COPY SITE MAP IN UNIT IV FILE,ADDRESS: t-I o j: y0m r4•. <br /> S . F11 F C O r <br /> WORK PLAN DATED: I 14;J01C <br /> Application Accepted By tn-� Date Issued 513/B$' Area <br /> S I Final Inspection BY IA1 Date 90/0,!r <br /> Grout Inspection ByL( Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3sof ''� 1�6YS (� Sri SR# 5 7r3 <br /> C-57_ WC=WAIVER_. C-57 Letter of Authorization to sign permit!Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />