Laserfiche WebLink
OL I <br /> " �, <br /> Joaquin County �— EI ''� E <br /> Environmental Health Department NOV L 9 2010 SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209) 468-3433 Web: www.sjgov.org[�, ONMENTALHEALMNIT IV <br /> Well Permit Application t PERMIT/SERVICES <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 /> 5 i 3.7 Assessors <br /> WELL Location I +Svy:4- V'v -oir� l;.-,r..�Cross Street t .rt:-.�: 1 - >City Zip `i) 7 Parcel# Lai -I 10 " <br /> PROPERTY <br /> Owner e1 C,- Address City�Zipl$J7) Phone# L�; <br /> C-57Contractor V Address �-' 3 ��� City 't"' Zip`1S110 Lic# Phone# <br /> Consultant/Sub Cntr _ Address — City Lic# - Phone# '— <br /> GIS Coordinates: -rLi. _i b 1y" ,Y;j 7.711 7 Township S Range N 6 Section H <br /> WORK TO BE PERFORMED: <br /> '#NEW WELL/BORIN'= '^^' "------ HYDROPUNCH,HAND-AUGER,OTHER-) g DESTRUCTION (choose type below) <br /> 'SOIL BORING# g OVER-BORE. DIAMETER <br /> ^ 'WELL# 101� .}�R-t d 0. , i• fL - G�/S I (�(S-Z a PRESSURE GROUT <br /> 0`Other _,7� ` / GROUT SPECIFICATIONS <br /> COMMENTS: 201 lirP.P.�iJ p�QttO �/ (.t-i�> 4 16' LA25"Z _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING X''1 4HOLLOW STEM DIA.OF BOREHOLE_` a MULTIPLE CASINGS G MULTI-LEVEL WELL CASING DIA:— <br /> u EXTRACTION/ AIR HAMMER/DRIVEN CASING THICKNESS 'Sc"" Ho TYPE OF CASING: a STEEL If PVC a OTHER: <br /> VAPOR 6 MUD ROTARY DEPTH OF GROUT SEAL ^''O- ' TREMIE TYPE TO BE USED: G-AUGERS a HOSE <br /> AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 8 Yes g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') C <br /> 'SOIL BORING IYB- ¢HAND AUGER GROUT SPECIFICATIONS N"--t- <br /> g OTHER:_G OTHER APPROX.BORING DEPTH -I 1�' G' g BOLTED TRAFFIC BOX or (STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ,w (if YES,list specifications in comment section) <br /> COMMENTS: <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 this application and that the work will be done in accordance with San Joaquin \` <br /> County. 'nances;Rules nd Regulations, and all applicable California State Laws. <br /> Signed x ^' Title/Company r`�. 11'�Js 42x <br /> Print Name Date-I l-I S� - 2-Dl O <br /> DEPARTUSE ONLY' <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 7<gMENT 5�6 <br /> WORK PLAN DATED: yo l0 <br /> Application Accepted B Date Issued Z/G / / Area. Ot¢ 1 <br /> Grout Inspection By Dat ^! Final Inspection By bb Date <br /> Destruction Inspection By ate <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ZRO SR# 3 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign perni Encroachment doc <br /> EHD 29-02-001 tT <br /> 6/22/04 <br />