Laserfiche WebLink
•n 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 <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES t 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 the Standards o San Joaquin County Environmental Health Department. ? <br /> n(� 1 C,� Assessors .I'7J-6/a_?/_ <br /> WELL Locatlona�d`l grrniµ,I�y Cross Street r City �� �(� Zip I'D�6 Parcel# U/ Jf� <br /> PROPERTY uu,^, I M Wk a0 Phone# <br /> Owner � OuIIr1�ll1�{II�a', '1l I Address ✓ //Ilt�l SP/� City�Zip� I <br /> C-57 Contractor's Q(JUJrw, IIDfik 4{to Address r5og� /&A„ City Rio �isln Zip 9y57/Uar jLVj phone#70737V-V3o0 <br /> Consultant/Sub Cnbr5'rjys &vi(or1/IfWJi Address 3330611/1/ Perk p(.J'5_'_y PW Li,# Phone# S--G7G�21)b? <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ESTRUCTION (choose type below) <br /> 0 SOIL BORING# VER-BORE. DIAMETER 8' /0/) <br /> a WELL# PRESSURE GROUT <br /> n`Other q ,M GROUT SPECIFICATIONS <br /> COMMENTS jfV /iij A'tW-j I j Mk/-� — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE_ O MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC 0 OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> u SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: B OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> �p 1 ��n ,I CO{JDUGTOR EASING rOPOSED (f YES,list specifications in comment section) <br /> COMMENTS: /1-{�5iru Pica (�^1U'A`6 (�dr/lAn bo PC�taP/� I'0 IaW <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 Ordi ances, Rules and Regulations, and all applicable California State Laws. <br /> Signed C'�,}V{ V[[[L J�, / Title/Company �G9�15* I S 4Y 5 Fnu7�nrYtl'. fJ �l'+�� <br /> Print Name Jam"' 17��� I I�I",,zDate 8-a �-o8 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z Z K r"`'��o} t o U Lo✓� S <br /> WORK PLAN DATED: u�w 20o��^ u q <br /> Application Accepled8y Datelssued IIZZ/�° Area'ML <br /> Grout Inspection By Date/ G D Final Inspection By Dale <br /> Destruction Inspection By Date It <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D SY DATE PERMIT I SERVICE REQUEST# tN`fOICE <br /> 35.62 60 ' 60' I1Ito3 sR#ooSS`f3g <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign Permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6122104 <br />