Laserfiche WebLink
Signed x <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: iTi(k <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br /> <br />Title/Company <br />Date <br />DEPARTMENT USE ONLY <br />3 0 t4 LAViD <br />Date Issued 3(02// 0 Area <br />Final Inspection By Date Date <br />Date <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <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 />Assessors 12 e="6- <br />WELL Location t <br /> <br />% 440-1- Weloetz- Ake_ l Cross Street 3erittio City 1341>c-k-Hs- Zip 15-Q- -- bg- Parcel# (1--i-1(;1 q14--r <br />Owner <br />rETY A <br /> <br />-O A'\ d-O Address 3 (4 -e•PA-- kr, City S--ke-t4111:5A Zip9531)3--Phone# (2-046 S 4441? I <br />C-57 Contractor V 111.14,a-4 Tetloo I le§Nddress?0 tCA CitykkisLzipqc4i1c. Liate11460 Phone# 65,4) -al 041 <br />Consultant / Sub Cntr 6014 ofacito eckp Address V38 fizAnklkied eincE City ,A-ce...kft>y\ Li dt Phone#6.7--159_) 01-'64 <br />GIS Coordinates: X , Township Range Section <br />WORK TO BE PERFORMED: <br /> <br />a NEW W LL / BORING (r <br />SOIL BORING # a ELL # a *Other <br />A-PP P-e)Y- a OVER-BORE. DIAMETER <br />a PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />EOP: HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />COMMENTS: 1-3.);21/1X7c 4.t3/)-7e.grAWALQATP--1) —S—AnApi,E S <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />O MONITORING a HOLLOW STEM <br />DIA. OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />fl EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br />a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br />0 AIR SPARGE/ OZONE XPUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes 1:1 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />2$,OIL BORING a HAND AUGER GROUT SPECIFICATIONS <br />a OTHER: a OTHER APPROX. BORING DEPTH a BOLTED TRAFFIC BOX or a 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. <br />I hereby certify th have prepared t s application and that the work will be done in accordance with San Joaquin <br />County Ordin ce , Rules and ,Rins, and all applicable California State Laws. <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# F <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />O1 1 3pqA27 sR# oc6c-vi 6 <br />C-57 <br />WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br />EHD 29-02-001 <br />6/22/04