Laserfiche WebLink
I *an Joaquin County ��o <br /> Environmental Health DepartmellYtl w r' SITE <br /> 600 E.Main Street,Stockton,CA 95202-3029 MITIGATION <br /> • (209)468-3449 Fax:(209)468-3433 Web:wwwsjgov.orgA9(F ` 9 2008 UNIT IV <br /> Well Permit Application ENVIRGNMIENT HEA4rz1— <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSJEbRM IT./SERVICES <br /> Application is hereby made to San Joaquin County for a per n t 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 \\C) �.Xoyy ely- Cross Street�JlC � Jl.City � Zip�0. � Panxt <br /> PROP RTY r�t� <br /> Owner v �11ho eAddreslw� 6m �\3q qY7—City iO-L zip rl5ca`II Phone#_Zq ''-L}- Q_yal lnOC�7a y� <br /> C�7 Contractors 1\1 Address `Y V�X l 1 l/ city`-V Zip -IJ�)LILic#�I/-O r Phona#dLT!-�LL�I-��W <br /> Consultant l Sub CntrV„�\ Mush AddressPDC \5a city\ -Yxlb�"'�a# Phone#r7'(Y-1-�'�(a9-9'IC3( <br /> GIs Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# a OVER-BORE. DIAMETER <br /> WELL# Lt- A ak OYhP Ott aPRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPECONSTRUCTION SPECIFICATIONS if <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE`' JEMULTIPLE CASINGS PULTI-LEVEL WELL CASING DIA:C? <br /> IKEXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 50140 TYPE OF CASING: a STEEL JKPVC a OTHER: <br /> IVAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> p AIR SPARGEI OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> u OTHER:_O OTHER APPROX.BORING DEPTH UO ' BOLTED TRAFFIC BOX or a STOVE PIPE <br /> nC�ONDUCTOR CASING PROPOSED NO (if YES,list specifications in comment section) <br /> COMMENTS:�`^'� �TJl1'�Y�\Q I>Yl Wfaa`J -e,--,ba W(tVW ,3QU V)OWr- Dyck Z"Y UO, A V,V-Zf-111J� . <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that have prof are I this app'' tion and that the work will be done in accordance with �n Joaquin <br /> County Ordinan as, Rt les and R ulations,an all applicable California State Laws <br /> � Y Gr <br /> Signed � �p TitlelCompany <br /> Print Name Y\Y <br /> DE RTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: lYr c(, k U lZW a Cid f U E ' u/� s ✓ 2�l'6� <br /> WORK PLAN DATED: J� tt r� O <br /> Application Accepted By Date Issued Y O-t Areaq13 <br /> q3 <br /> Grout Inspection By Date7Z Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PECODES FEE INFO AMOUNT REMfTTFD CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> dRo 8 - if �l0 p S oos�glS <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001web <br /> 622/04 <br />