Laserfiche WebLink
'Ran Joaquin County [RE�LomwIn <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95205 E P g 0 2008 MITIGATION <br /> 1W (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.��E/ehdNN1ENT HEALTH UNIT IV <br /> Well Permit Application t vTPVv�IEFRMIT/SERVIC <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a peril 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 /> M Assessors <br /> l� Coss Street iG dzip �C�Parcel# <br /> WELL Locationn Gty �'1 q <br /> 1 I 1-rlv <br /> PROPER 11 1, (L, L��� ct <br /> O,wrer �S N � P.ddressa�n Uwi wq4 CityJ�_Zip 15x0 Phone# <br /> C57 Contractor Wo,duwIID'- �li''W�n Addree,ss 55o�� j ,� City �rc bison Zip 9`l5� Uc* 71007 Phone*Z07-37y-V300 <br /> Consultant/SubCntr ±t'jLS -✓Ivi(ort/1BI"iAddress3316 Grnfam P.rkDr.JctYca'�+MIA�I(Ua����z Phone* f3>-G7/o•�Gz <br /> GIS Coordinates:X .Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> g NEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER`) ESTRUCTION (choose type below) <br /> a SOIL BORING* VER-BORE. DIAMETER S/t <br /> 0 WELL* PRESSURE GROUT <br /> u'Other GROUT SPECIFICATIONS <br /> COMMENTS: Oval —61 -W -P — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> .10NITORINGIOLLOW STEM DIA.OF BOREHOLE_ 8 MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION u AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL 0 PVC a OTHER: <br /> u VAPOR 8 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE CY <br /> 0 AIR SPARGE/OZONE 8 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 8 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') o <br /> 0 SOIL BORING C HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: R OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> II C',peNDUCTOR1CASLNG/PR/p'POSED (if YES,list specifications in comment section) <br /> COMMENTS: �N jtlrlh�berh we 1.;0 TK �OMS7yLlA[Gf 1%Wi ht A'VCf/�r(4'. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. tf <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi antes, ules and Regulations,and all applicable California State Laws. <br /> Signed x 7"r'�r I./C / TitlelCompany (P 154 /Jjyu 5 G nut ran v te� ' <br /> Print Name J0' �ITit^�C Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z M4A.L. oft./ k1l • to r UO- b P <br /> WORK PLAN DATED: 7-008 <br /> Application Accepted By Date Issued sl yq UOy <br /> Area �97 <br /> Grout Inspection By Date/ 0$ Final Inspection By Date <br /> Destruction Inspection By Date ( (e rfig <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID* FAC* <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK* REC'D BY DATE PERMIT:/SERVICE REQUEST* INVOICE <br /> 3$ gyp°! 0.00 (7v 8a /cyl� 9�7y o� SR#ODSrS�2Z <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6122104 <br />