Laserfiche WebLink
WELL ERMIT APPLICATION FOW SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 /> p /• WCros <br /> Assessor'WELL Location 7A � (LJ � s Street U/W City QZl6 OW Zip�Parcel# / <br /> r i 3( WicS1 Lf1 ty� 74ff p9sz�9 Phon g70 -7771 <br /> PROPERTYOwne� (� .s�lyAti�- Acddress 7E f/ �auT Ci Zi <br /> C-57 Contractor A. Address 1177V,4W,/ Ci�calZi Lic#1 e <br /> Phon ' t'd T'l� <br /> b 1 <br /> Consultant!Sub Cntr (,f Address h Sf/I _J AW City57r C f�1 Li ZZ7 Phone <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PER R D: <br /> NEW WELL/ OR (CPT, OP ,HYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION(choose type below) <br /> XSOIL BORING# [I OVER-BORE <br /> �7a ELL# ././nt ESSURE GROUT <br /> 'Other: L SO l L �L�fZc.�LGS 2nd Zr- Grout Specifications:'Pid V / 7f'`� <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> G MONITORING Q HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS? MULTI-LEVEL?Q WELL CASING DIA: <br /> WA <br /> H EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESSTTYPE OF CASING: a STEEL B PVOTHER: <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL L TREMIE TYPE TO BE USED: AUGERS a HOSE <br /> a AIR SPARGE/Ozone�USH POINT GROUT SEAL PUMPED: Q Yes o (NOTE: MAXIMUM F EE-FALL DEPTH IS 30') <br /> ')`OIL BORING 1]HAND AUGER GROUT SPECIFICATIONS: �7 71 4.4 ty lY�4f ZZ <br /> G OTHER:_a OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR.CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that I have repared this application and that the work will be done in accordance with San Joaquin <br /> County I pnc egulations, and all applicable California State ws. <br /> 1 !!II Signed x Titie/Company '� &MA <br /> Print Name G �6� ��" Date 6 -9-1(o , 03 <br /> - ,�D//EPARTMENTU//SE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z-U <br /> WORK PLAN DATED: 7ug., /�O Zod 3 <br /> Application Accepted By Date IssuedArea D <br /> Grout Inspection By Date Final Inspection B i_--%_ Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FA <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 0 5�2� 40 �� <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br />