Laserfiche WebLink
�n.Joaquin County <br /> Environmental Health Department SITE <br /> 600 E. Main Street, Stockton, CA 95202-3029 MITIGATION <br /> j2'01l` 'j,0 ';3,49 Fax: (209)468-34.33 Web: www.sjgov.org/elid UNIT 111 <br /> ``_. l i Well Permit Application <br /> c )I(91L�6 NDABLE PERMIT EXPI_RES 1 YEAR FROM DATE ISSUED <br /> i ) <br /> ra <br /> Application is hereby made to San.Joaquin&gpq ,for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Devplpet(t_ITR�!;Ishapet and the Standards of San Joaquin County Environmental Health Department, <br /> r � t L :.1 h, h°EAG�RtIEill`t _ Assessors <br /> WELL Location Siva." t &I Cross Street I�I V E City t 0,A CY Zip 9 53 4 6 Parcel#'V3_S_)9 01`j <br /> PROPEITry Ct7VNI1 0t 5A 4-6A0VIN <br /> Owner FA�, MGI�IT. Uri Address_II II t, �C011 A�t, City-S10'4TOI-Zip9y205P.hone# (209) 468 9e'Z5 <br /> All W9L L <br /> C-57 Contractor A �$ <br /> ApRh11�DNM� �:.I" actress 09 {'lr:A3nii7VALLEY c;rypi.Aci`Rd'1llkip!}Eb L'€c#$483�9Phone# (E00) 9 1$J'35.� <br /> ttAMAC� y <br /> Consultant f Sub Cf* V r NCAddress_ City R F Id G Lic# 9 Phone# <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> U NEW WELL!BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ' 1 DESTRUCTION (choose type below) <br /> SOIL BORING# i OVER-BORE, DIAMETER S—I N C 14 <br /> WELT# 0 PRESSURE GROUT <br /> 0*Other' GROUT SPECIFICATIONS <br /> COMMENTS: 0 L 5 T R V Cj 1 C H OIM V N I t O A I N C- W El t 3 <br /> TYPE OF WELL CATION TYPE CONSTRUCTION SPECIFICATIONS <br />` MONITORING j HOLLOW STEM DIA.OF BOREHOLE S r! 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5C14 40 TYPE OF CASING: p STEEL ®PVC U OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 3 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE. <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL_BORING 0 HAND AUGER GROUT SPECIFICATIONS NEAT C I;til I_H T <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH' 'zo , BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED IN A (if`YES,list specifications in comment section) <br /> COMMENTS: ytoAyC TIGN of I MON (10 MNt- W:LLL5 <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x c' Title/Company_ E R.E S 1 D t N T '/ A M 4 &t E N V I R O M PI rR I I INC. <br /> Print Name ATO S t r 14 R 4 M A C E Date?-4 0,le <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: $I':n jv t <br /> Application Accepted By (A' A Cite Date Issued_ j C2 �2 Area <br /> Grout Inspection By Date t Fihal Inspection By Date 1 d <br /> Destruction Inspection By Date.. <br /> COMMENTS!CONDITIONS: <br /> I ACCOUNTING ONLY: AID# <br /> FAG# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK 9 RECD BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 35'e2 60-00 <br /> .S' (.ems to r�/a� SR# S- <br /> C-57-- WCC-WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EHD 29-02-001 web' <br /> 6122104 <br />