Laserfiche WebLink
2/ 2 <br /> 09-0E-08:01 :03PM: • <br /> oDln SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> " Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.siciov.oralehd UNIT IV <br /> 9�IF0 � <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work desuibed. This application is made In compliance with San <br /> Joaquin CountyAevelopment Title,chanter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. Assessor's (-d0,3�00/ <br /> Well Location -2SOE rPo{'�I l�Lll• Cross Street"''/flw IV17f /GK/N�LL,Cityxlov- -ph�� Zip 7 Parcel# /9 <br /> Property ,,�, ,,/ y��� y�iO�R✓!-'• Cily Zip •3'>PPhone <br /> #5 06�'Z-Z8'2�f <br /> Owner 'OM 0/,'lU 7"��[�/dress /9���������LL�� nn,, <br /> C. <br /> Contractor Wi/G Address ��D Wyff36I/� City �`�--Lic# _Phone <br /> Consultant/Sub Cntr (lRS Address 2590 la---1CWz ©�S City + Lic# 62 <br /> Phone%/ 5/3 <br /> v, 1ISO Range Section <br /> GIS Coordinates:X y jo O <br /> Wj1RK TO BE PERFORMED: DESTRUCTION(CHOOSE TYPE BELOW)NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND.AUGER,OTHER-) ❑ <br /> ROUT❑SOIL IO <br /> ❑OVER-BORE DIAMETER <br /> ELL# MW52� Q MW 27G17) MW527DK ❑PRESSURE IFICA <br /> [3-OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE �� MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION '❑�AIR HAMMERIDRIVEN CASING THICKNESS �,� TYPE OF CASING:❑STEEL��./PVC ❑ ER <br /> ❑VAPOR yQ MUD ROTARY DEPTH OF GROUT SEAL 1 r.AJ TREMIE TYPE TO BE USED ta)AUGERS HOSE <br /> ❑AIR SPARGEIOZONE ❑I PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:t6.s O No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30) <br /> [I SOIL BORING (3 HAND AUGER GROUT SPECIFICATIONS p�� �/ <br /> APPROX.BORING DEPTH 6 r/ 170/ Z•3O,lR oOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> ❑OTHER: ❑OTHER: CONDUCTOR CASING PROPOSED ' Or YEs,llsl¢peaimtions In wnimme 8e n) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> hereby certify that I have preparpd this application and thatthe work will be done I aceordancewith San Joaquin County Ordinances,Rules and <br /> Regulations Ila Alice a alifor la lLaw . `.-�7 /'•/'��/O�`� <br /> Signed !/^ /nY^r �a TitlelCompany <br /> Print Name �c-1 (7 I Date <br /> �t Q/J�,,��// DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: U/�O P., _ O ��(���'r <br /> WORK PLAN DATED: CVQ <br /> APPLICATION ACCEPTED BY DATE IS UE a 0 AREA ! yI <br /> GROUT INSPECTION BY FINAL INSPECTION BY DAT b !7 D(J <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: WS <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> SR#06239? <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> EHD 29-01 1115107(WEB) <br />