Laserfiche WebLink
i{ <br /> 'o 09 County 1 �� ( L? � n/ I� <br /> w � San Joaquin Coun nl , (� � <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.sjgcP 0TWTY1c , , ENT HEAD 1-I UNIT IV <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 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 /> 8604 77�9�71nW /� �SZdy Parcel#Assessors <br /> WELL Location Cross Street �A-✓ City STa�F1Ar"i Zip <br /> PROPERTYA -7 <br /> Owner / // �f Address /� City/�l.J/s�l�i /vZip �01�11✓7o Phane# �/� /gp <br /> C-57 Contractor Z,.f3G/1L16 �Z CJ4Address .73430 OMf-G �i,IL cityC011�yd� Zip /.Jv/�Lic#7/7.�d Phone#A6'+ .rg e�6lf <br /> y� �AAc� <br /> Consultant / Sub Cntr SGGa� jJ <br /> Address 30/7 NL +'i ii� 4 City�Q�°✓�Lic# Phone# <br /> GIS Coordinates: X., Y., Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER`) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING # O OVER-BORE. DIAMETER <br /> WELL # S%F� a PRESSURE GROUT <br /> [] 'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 7/ <br /> o MONITORING HOLLOW STEM DIA. OF BOREHOLE 8 r [I MULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA: <br /> p EXTRACTION ]] AIR HAMMER/DRIVEN CASING THICKNESS -ir� 40 TYPE OF CASING: [I STEEL *VC [] OTHER: <br /> VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL O pTREMIE TYPE TO BE USED: [) AUGERS HOSE <br /> a AIR SPARGE/ OZONE [] PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes ArNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> () SOIL BORING [] HAND AUGER GROUT SPECIFICATIONS /tl4ro,0T Gtr- // - <br /> o OTHER: [] OTHER APPROX. BORING DEPTH 5 OLTED TRAFFIC BOX or o STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (If YES, list specifications in comment section) <br /> COMMENTS: <br /> I <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS AGREEMHNT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED, FOR INSPECTIONS. <br /> V <br /> I hereby certify that I have prepared this application and that the work *ill be done in accordance with San Joaquin <br /> County Ordinances, fjul sand gulations, and all applicable California State Laws, <br /> Signed x ///A/j/ h Title/Company <br /> Print Name ` G /~�� �/r!7' �L� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED : 0 <br /> Application Accepted B 6Date Issued V// Y Arqp 9 f 7 <br /> Grout Inspection By Date '/-" Final Inspection By Date 2404 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: S Ol JyP <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> S200q/ 27 Lop <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />