Laserfiche WebLink
at' ns, and all applicable California State Laws. <br />Title/Company • <br /> Date <br />DEPARTMENT USE ONLY <br />30 t4 t,Oe_ber- <br />64k7-4 rem Luc <br />1407 <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 e , Rules and ,R <br />Signed x <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />A-- WORK PLAN DATED: <br /> <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />*21/0 <br />Date Final Inspection By Date <br />Date <br />Area Date Issued <br />glikan 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 />?I Assessors <br />WELL Location th Ne-62- Cross StreetAt\ 3critt 03 City 5-bckfc5-1.. Zip griab.?-- Parcel# <br />PROPEZTY I 44) <br />Owner --)1)11 (JO 16,A 60 Address3 6“11'4f43-“Lkir--City Zip Phone# (2-191)46 8 <br />C-57 Contractor \IOW Ite-6-4. 16,ddressCO .60'4 Lic#6(4/t) Phone# (61,a <br />Consultant / Sub Cntre4:1'41(X--6/WriA ef—kil Address V38 f1414-11<-6.18.ae City shpe..-14fY\ Li c# Phone#(1--(-59)A-4 <br />GIS Coordinates: X , Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( HYDROPUNCH, HAND-AUGER, OTHER*) fl DESTRUCTION (choose type below) <br />SOIL BORING # <br />U OVER-BORE. DIAMETER <br />0 ELL # <br />0 PRESSURE GROUT <br />U *Other <br />GROUT SPECIFICATIONS <br />COMMENTS: .3/4.- A A.V) wi4TEJ,-) S51-nAN r <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING a HOLLOW STEM DIA. OF BOREHOLE 1:1 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 1:1 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE XPUSH POINT (GP or CPT)GROUT SEAL PUMPED: 1:1 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />XOIL BORING G 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 />COMMENTS / CONDITIONS <br />ACCOUNTING ONLY: AID# F <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />'2 o ( 31 $1 31,q/i2 sR# 00 c-?// 6 <br />C-57 <br /> <br />WC -WAIVER <br />C-57 Letter of Authorization to sign permit Encroachment doc <br />EHD 29-02-001 <br />6/22/04