Laserfiche WebLink
County Ordinan <br />Signed x <br />Print Name <br />nd Re ons, and all applicable California State Laws. <br />Title/Company <br />Date <br />Application Accepted By a#441\_ tytA.)- Date Issued <br />Date ///2- Final Inspection By Grout Inspection By Id eA.A._04....,( <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: //114.114/5 Z- 4-z441-44-C <br />IEC.7 VE:a WELL PERMIT APPLICATION FORM SITE <br />NOV 11 7 2n. - • ---rnITIGATION <br />\iMENT HEUNIT IV <br />IT/SERVIM; <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 />k L Assessors <br />WELL Location 4'\'\\A:k t. Cross Street 'FOCe• WRie, City SA7,GY--41:)V) Zip Parcel# <br />PROPERTY Owner S rj. SalActvwc, Address 23ST1 Crt s-Irckleklill City Ctl,S+11 \121t1 z < 'S?- Phone# 510 - 110 - 5100 ex-A- • <br />C-57 Contractor *513 .---01;ttk Address 950 4101P-C-• la • City VtarkiNt Zip9453 Lic#40:75 Phone# 92-5 31 3 -5B00 <br />Consultant / Sub Cntr Cam byi A_ eriV, Address 210 F'e)r LAS Si-• City SO-116W) Lic# Phone# 701 - 93b —i8S0 <br />GIS Coordinates: X , Y Township Range Section <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E. Weber, Third Floor, Stockton, CA., <br />(209) 468-3449 <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />U SOIL BORING # <br />WELL # <br />fl *Other <br />COMMENTS: <br />,aDESTRUCTION (choose type below) <br />D OVER-BORE. DIAMETER <br />k-PRESSURE GROUT,, <br />GROUT SPECIFICATIONS roeiv-K0- vi ti <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />\211ONITORING 0 HOLLOW STEM <br /> <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />valAPOR 0 MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS U HOSE <br />TYPE OF CASING: LI STEEL 0 PVC a OTHER: <br />0 AIR SPARGE/ OZONE a PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yes <br />U SOIL BORING U HAND AUGER GROUT SPECIFICATIONS <br />U OTHER: a OTHER APPROX. BORING DEPTH <br />0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> <br />0 BOLTED TRAFFIC BOX or U STOVE PIPE <br /> <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 that I ha. e p epared this application and that the work will be done in accordance with San Joaquin <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE T # INVOICE <br />3O 2- &oc'• 6r11-' 7. 0 141k— <br />C-57 <br /> <br />WC -WAIVER C-57 Letter of Authorization to sign permit <br /> <br />9/30/02 <br /> <br />a •• <br />