Laserfiche WebLink
00 u co SAN JOAQUIN COUNTY <br /> i ENVIRONMENTAL HEALTH DEPARTMENT <br /> A SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> P 0 Telephone: (209)468-3449 Fax: (209)468-3433 Web:wwW.sigov.org/ehd UNIT IV <br /> �rFOR� <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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> H 1614 W A Y 33 Assessor's <br /> Well Location 35 2-75 WL7`f ROAD Cross Street City V UNALI rj Zip 96385 Parcel# 255-116,6-69 <br /> oW�e y(,rSL E JANE ►�CNENERY ,��d,WTBK ME dre 31 MAtW DRIVE citykEWFIELl7 zipg4g04 Phone#415'256'1965 <br /> C-57 Contractor RSI W ILUNEI Address 220 N. FAST ST cityWlQ)X.a1�(D Zip g5�76 Lic# Q�23�Jg Pho3e0 668 <br /> 2424 <br /> Consultant/Sub Cntr SAAddress_3800 WATT AVE.,V ITE�ZIOy SA rAMENTp Lic# — Phone Ib'R79 '2✓7 96- <br /> GIS Coordinates:X 'Y Township 3 =7'0 Range b E14ST— Section 3-if <br /> WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ESTRUCTION(CHOOSE TYPE BEll <br /> ❑SOIL BORING# OVER-BORE DIAMETER to <br /> ❑WELL# PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS N M <br /> COMMENTS: V651MO'{ I Ca Ie0Un/PrVA7S9_ VJJ;L_ (14W-4) <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE $'rJii ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:! <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS SCUD f O TYPE OF CASING:❑STEEL$PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL �TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes*KNo (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS 0El`#Dj4 ITE 6tR0UT- <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 455 ❑BOLTED TRAFFIC BOX OR STOVE PIPE <br /> CONDUCTOR CASING PROPOSED IVPI (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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and I applicable Ca or is Laws. <br /> Signed Title/Company Fle0,jf_GT JA'4I1209f-AeW-AL-SCIENCIST /SR IL. <br /> Print Name L-ATZ jeY 5 I LVA Date 512,1013 <br /> _ <br /> -7 DEPART1MENT USE ONLY <br /> � Q <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> 4 <br /> WORK PLAN DATED: �1.O 2007 <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA 2 <br /> GROUT INSPECTION BY gzf FINALINSPECTI N Y DATE <br /> DESTRUCTION INSPECTION BY DATE 3 <br /> COMMENTS/CONDITIONS: �D <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 0 07 6oc� C, i l' SR#00 yrs c� <br /> C-57 WC -WAIVER C LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5107 WELL PERMIT APP <br />