Laserfiche WebLink
�oPQUtN oo San Joaquin County <br /> Environmental Health Departmep�t SES �� SITE <br /> 600 E. Main Street, Stockton, CA 95202-3029 �4 <br /> 9.1"/ s<, MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.or / 9F� ��� UNIT IV <br /> mat NSP Well Permit Application isFR cFq�r <br /> tppR <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Fs <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 /> 35-/Oz) S'OLW 5{rt•�e 2at�{�33[[y��.�� '/ Assessors <br /> 3 <br /> WELL Location �+"'yCrossStreetSC,/G/ City N(ot4hS zip 9'5M5 Parcel# 255f 9llD�l <br /> PROPERTY II <br /> Owner /leSrern frvt�lnrlGG Address �D L�»X H4CityFM540 Zip93l/5 Phone# z09 T3'S'�5g� <br /> C-57 Contractor. -h/'Oh Address City '" / Zlip Lic#�j00;hone# <br /> Consultant/Sub Cntr Address 475/N �v�._4�z qW City Da�-I�O� Lic# Phone#$/ 34rD <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> D NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') D DESTRUCTION (choose type below) <br /> D SOIL BORING# D OVER-BORE. DIAMETER <br /> D WELL# D PRESSURE GROUT <br /> Other // S GROUT SPECIFICATIONS <br /> 4/Z- <br /> COMMENTS: //IICGi/' VY6 -7b 49 6r_0Z46W( ,7 Gcl A�u5kd - kl t, . <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE D MULTIPLE CASINGS ,MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE/OZONE 'Q/PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') o <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS Q <br /> D OTHER:_0 OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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. w <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin W <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws.J� <br /> Signed x i( Title/Company (S" <br /> Print Name Date O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 3flDO w <br /> WORK PLAN DATED':' &LCkDI ,060 <br /> LIg <br /> Application Accepted By Date Issued 76-0/07 Area��7 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS:DYE^ p tDh, <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �J,9f F9- 89" ;b&o 44- _128$3 <br /> C-57_ WC WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001web <br /> 6/22/04 <br />