Laserfiche WebLink
o�9 T. :r San Joaquin County <br /> Environmental Health Department o ��(� AGATION <br /> SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 952 `� <br /> (209)468-3449 Fax: (209)468-3433 Web: w,,vw.sjgov.org/eh UNIT IV <br /> C T 2 5 2006 <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUENVIRO�/ENT HEALTH <br /> °bERMIT/S�RVI���i <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applica ion is n compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. ilr/-12- G/ <br /> ,y aAssessors 1-1-/ -I L-0 L <br /> WELL LocationL0 0 7 0 W i/iGtti/a�cross Street� Q4s5 City tri Zip t-3 7� Parcel# 7-51 a3 <br /> PROPERTY � � JyLne7J/ �tCpfy -�Of)Owner� Awa,'�G4,/AddressL73/ Or, City wiof ZipY � f $/ <br /> Y <br /> C-57 Contractor i)1 W 0r;1\its Address PC' C� LI City 1S&c. ' Zip nt 6-( Lic# Phone# IG 777-4(oo <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X 'Y Township 3 5 Range �{ G Section <br /> WORK TO BE PERFORMED: <br /> .NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> S SOIL BORING# I — u COVER-BORE. DIAMETER / <br /> fl WELL# 0 PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> '.MONITORING jHOLLOW STEM DIA.OF BOREHOLE�' MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS — TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALT-k1 tc-:%�_TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: &Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> gSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONSAAWA&b--+-,^�+L <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH Z-1- — ` 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: 52Wf-- levy k--, \?.o' , 1— h— o.•.b--jn- 4Lct� vial �w-pOcl�l Fc� 11w'S <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 ' ances, Rules and Regulations, and all applicable California State Laws.. �) / <br /> Sign 4�v ! Title/Company zle "/-�.4• (///!/t,/ Cts <br /> Print Name �-i�-� c/. �� Date ��•1� b <br /> DEEARTMENT USE ONLY <br /> v <br /> SITE MAP IN UNIT IV FILE, ADDRESS: D 0 14) <br /> WORK PLAN DATED: <br /> �/y� 1 �-5 fo _ <br /> Application Accepted By 1 r l Date Issued f���Area <br /> Grout Inspection By Date a Final Inspection By i E13te <br /> Destruction Inspection By Date <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 /> as 6 l 333 y SR# L4� 3 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Enc�hment doc ✓ox <br /> EHD 29-02-001 <br /> 6/22/04 COPY <br />