Laserfiche WebLink
FILE COPY <br /> U'IN San Joaquin County <br /> KEnvironmental 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 / L <br /> P <br /> ao Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Z Jv/� <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made 1fi compliance with San <br /> Joaquin ouni­y Development Title,C pier 9-1115.3 and the Standards of S n Joaqut Cou ty Environmental Health Department. <br /> yj Assessors /�,,� <br /> WELL Lo4atlor Cross Street (ya(/rCitly Slad'-40, zip �'$�D} parcel# /�wUj <br /> PROPERTY ,, // j 7 <br /> Owner i Address n /V, ily �# �� Zip Phone#—�/ <br /> i C-57Conlmetor Addres41110 4/r:,„,c Ave, City lepep�a,.. Zip MS ) Lic# Phone# <br /> Consultant/Sub Cntr L-FA.-T"f. Address 000) I"OWpll S1, City twur• :llf phone#(41C� <br /> I?-th <br /> Fico, <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> $NEW WELL/BORING (CPT,GEOPR_OBE,,HY�D�R�O/P�UNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> pWEILL#LSORING# «/I�If N1,TYi� 0 OVERBORE. DIAMETER <br /> p'Other - 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: Aj-P + CPT -Te lkv.olw)ioq w'II 6e j✓N O1QN.a ! A - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING E HOLLOW STEM DIA OF BOREHOLE, ' 0 MULTIPLE CASINGS u MULTI-LEVEL WELL CASING DIA: <br /> n EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL G PVC D OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL to S q TREMIE TYPE TO BE USED: D AUGERS ,'HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes U No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: D OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Of YES,list specificatlons in comment section) <br /> COMMENTS: /I'I l ('. PT �r,If(,A —Tp r kooloA(-p$ <br /> U J <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certAy that I have prepTred this application and that the work will be done in accordance with San Joaquin <br /> County Ord' nces,Rules and Regulations,and all applicable California Striate Laws. <br /> Signed •�— Title/Company PfO�I CcA <br /> Print Name J ASOH �f t r)'O Dated 2y�O6 <br /> DEP RTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS; `tiC� <br /> WORK PLAN DATED: i (p <br /> Application Accepted By Date Issued 199 Ab .Area <br /> Grout Inspection By ate Final Inspection By a e G <br /> Destruction Inspection By Dale <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC* <br /> PE CODES FEEINFO AMOUNTREMITTiLetter <br /> ECK# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> I <br /> 047 <br /> f (o S D <br /> C-57 WC;WAIVER_ C-57 of Authorization to sign permit_Encro Ment do <br /> EHD 29-02-001 ,,r <br /> 6/22!04 <br /> l <br />