Laserfiche WebLink
'c FILE copy <br /> ;an Joaq�:nCounty <br /> �''� SITE <br /> Environmental Health Department ��� , <br /> 304 East Weber Avenue,3rd Floor, Stockton CAs9S 92 � / <br /> �� � ., � d � � � MITIGATION <br /> - (209)468-3449 Fax: (209)468-3433 Web: www.sjgov,. ` ec UNIT IV <br /> Well Permit Application1 41'1 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7-7 <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 of San Joaquin County Environmental Health Department. <br /> / Assessors <br /> WELL Location IL � P�Lt l'C�/e-+1� Cross Street ti City Ck . Zip 9� Assessors <br /> �t <br /> PROPEF�IY $$��7 � 3ZS <br /> Owner CO Addro,sssq !3�/� �� �[� qty �ir�!CrZip W7 Phone# 15c.7- 921 �SQ8/ <br /> C-57 Contractor Te5A- A>�✓°m p✓4( ress loll F-k-4eA-�N-c City ke—Zip�Z305 Lic# Y�9ffPhone#7j'� I�j l68� iD <br /> Consultant/Sub Cntr(-oflubO(clic(4 50"ddress> tt n1^C Su, Ci y �nh� is# '�55 2lo Phone# <br /> i <br /> GIS Coordinates:X_ Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> `)(NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> ASOIL BORING# 0 OVER-BORE. DIAMETER _ <br /> 0 WELL# 0 PRESSURE GROUT <br /> a*Other-- GROUT SPECIFICATIONS <br /> COMMENTS: „, `Q7v�f �$—� �D (oC'1 Qr.iO ✓ o ( 5 F �r� VNz� �Z+ uSl— ✓�/[s�t� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE [I MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:, <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSTYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: /)T-AUGERS XHOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 715Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_ fl OTHER APPROX.BORING DEPTH ('201 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED_ �(f YES,list specifications in comment section) <br /> COMMENTS: 1?, 4. LR �� w K a <br /> i <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 0-s application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rul and gul Ions, and all applicable California State Laws. <br /> Signed x_ � ' <br /> Title/Company <br /> Print Name c r V. ——� <br /> Date 62 L1 nom_ <br /> DEPARTMENT USE ONLY n <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: n <br /> Application Accepted By Date Issued D �/3 <br /> Area <br /> Grout Inspection By_ Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> "OUNTINGAID# <br /> FAC# <br /> AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> o0 S= IVER— C-57 Letter of Authorization to sign permit Encro ment doc <br /> ERD 29-02-001 /V/ — <br /> 6r22104 <br />