Laserfiche WebLink
G,. i i.:�E�';,�' i�- ENT <br /> ENVIRONMF SITE <br /> 600 East Ma: CA x'520 029 MITIGATION <br /> Telephone: (209)468-344 ; , Ci '�h:w'v/w.sigov.orq/ehd UNIT IV <br /> WELL PERMIT APPLICATION <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.$and the Standards of San Joaquin County Environmental Health Department. <br /> ti a t v v.un.L� Iro fir-'}, 'Mo.'�A'L %�LT��U- Assessor's �/ f <br /> Well Location Cross Street ~� �"'� City / / Zip Parcel# tt IMiy�y-f - <br /> Property V&_+ t 437 ���it� S�t'Tc) l)C�lw��K Zi 'L G <br /> Owner ! ,r Address �C I, City ) p' yV5`'7,9 Phone# 7� <br /> C-57 Contractor Fro Address of �&W eA ^V�t� �1 City`b' CjO VL; I/l Q Li/c� r ' Phone 5�U 5 � tel[ / <br /> Consultant/Sub Cntr t Address Z�3 /V ,/►'tA;-Iq /7 City W�`n�T C�rri?k�146! _;"PhoniaS LS 277i 5 0 <br /> GIS Coordinates:X �t t- Township Range Section <br /> WQRK TO BE PERFORMED: <br /> K NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> WELL# I U Q 'vV1 Q s,� ❑PRESSURE GROUT <br /> ]'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [I MONITORING [I HOLLOW STEM DIA.OF�OREHOL r�1❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ??ff /I__ /`7� [Itt�� 't K <br /> El EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS �Gyt D TYPE OF CASING: STEEL `}PVC ❑ OTHER v <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL T TREMIE TYPE TO BE USED P'AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE Y-EUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ANo (NOTE:MAXIMUM FREE-FALL DEPTH IS�30') <br /> El SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS ��r—r �_ <br /> / v1 <br /> OTHER: ❑OTHER: APPROX.BORING DEPTH BOLTED TRAFFIC BOX OR ElSTOVE PIPE <br /> CO DUCTOR CASIN ROP SED (if YES,lis specif cations in 96nXnent section) <br /> COMMENTS: Ct Q ti111 i <br /> NOTE: OFFSITE BORINGS REQUIR ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certit I have/prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulationsq5ddall a ble California Laws. <br /> Signed 9 Title/Company G�u'/LE+� ��� ✓ G�/y1P�i+/ ��ifi��-�' �7 <br /> B ✓ <br /> Print Name / Data <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: uu-" Y� <br /> WORK PLAN DATED: L owl <br /> APPLICATION ACCEPTED BY r DATE I SUE L Z AREA <br /> ff o <br /> GROUT INSPECTION BY [lam FINAL INSPECTION BY DATE 'Z <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RE V'D BY DATE PERMIT/SERVICE# INVOICE <br /> zwa ��•�:� <br /> a"_9A SR#Sb 1'`A <br /> C-57 WC / -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />