WORK PLANS - Laserfiche WebLink

Home Browse Search

f 111 S A NAAQ U I N Environmental Health Department 'f - —COUNTY- - Greolness grlTr;s 111:rc. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For INSPECTIONS Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This npplicallon Is made In compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Addross _501z City/StatolZlp ;��C1e��, CiE `)SLa, Phone CrossSlrool Ji. ("r",Q.-s APN �y�•• �`' tNu•c<Y1 ProportyOwner y5ry.," � C• Iwg,•,r•�r( Tr>^s� .+ir«._1_ -i .��`Iraclr.yo, Phone 37 C Address �� _ c,S`" Clly/StatolZlp ${"( - C-57Contractor EsRv�t LlcenseN _ /(:>)2-'LLS$ Phone Address Qr L% City/S(atolZlp Consultant/Sub-Contractor A. ek Colin ro)it& (nc. LlcenseN Phone `I'/6 Address IIZq l VLriAN Wa7� St+s Q� City/StatolZlp (B 'U4 12-�V�� rA I CONSTRUCTION WORK TO BE PERFORMED:'Note: Offslle Botngs/Wolls Require Access Agreements or Encroachment Permits TYPE OF WELUBORING lUt MBER INSTALLA710l1TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING ❑ HOLLOWSTEM BORNG DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑EKTRACTIGV(VapaAVatel) ❑ IMMER)DRNEN DIA.OF BOREHOLE ❑MULTInE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑SO:LVAPORPROBE ❑ MUD ROTARY CASINGTHICI(NES3 TYPE OF CASING:❑STEEL❑PVC❑OTHER ❑S00.BORIh'G ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes❑Ito W4Dia: Cau!rgDla: CasingDepfk ❑INJECTION(AMSoa ae.Otoral ❑ HAND ANGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED:❑AUGERS❑HOSE❑PIPE ❑OTHER ❑ OTHER: GROUT SEAL PUMPED? []Yes❑No (Note:kla*wrnFreela9 Depth Is30FQ WELU SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY! N WELLS TO BE DESTROYED 3 ❑OVER-BORE DL JAETER of Inches to depth of feel WELL IDs u rNw 1.1 c+ll., 1L WRESSUREGROUT To depthol feet befowsurface GROUTSPECCJNSO [I EXPLOSIVES From to feel belau surface TREMIE TYPE TOBEUSED ❑AUGERS ❑HOSE PIPE ELMUSHROOM CAP feel kW,surfacoor �-- feet belau surface If>3 feet COMMENTS: L t hereby certify that I am authorized to co plate this application and that the work will be done in accordance with San Joaquin Cop y-Ordl ance Code and Standards,and all other applicable California laws. I Signed Title/Company 01ce- 1- Prinl Name ,\��.�a•,C tt[�i�— Dale I DEPARTMENT USE ONLY Application Accepted By: t' Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dales: I Faclll ISlto Information FANamo4 - yFA Address FAN PRN 11� FA PE j l "1 WP RWewod By Work Plan Date ❑457 (:J C37 Autkdretol fa Olher to S!gn Permit ❑Woriccfa Comp ❑%Vofkefs Coup V1slver ❑Erloroadvnenl Perm:l ❑Aomss Agreement QLead Agency Approval Q011 COMMENTSICONDITIONS: To 045 l 3: Iv4 w y �� Cc�S✓ram ro4r�t—t' �� (—�d (jr��eJ�� WP TYPE F SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT/! INVOICElI Permit 1'11i 11 x 5-�-�- Pa 4 1868 E.Hazelton Avenue 1 Stockton,California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcetid.com E110 29-01 07-01.2025 Sao hl6gatl n Wed Pe mlt AppteaW