Laserfiche WebLink
Date Issued <br />Final Inspection By LEisztte 6-30.-60- <br />-05 06(15/ <br />Date <br /> <br />Date <br />San Joaquin County nRIGINA rticActe[ TAkertA <br /> <br />Environmental Health Deparit,nt SITE <br /> <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 952 17 I1\\ if-MITIGATION Nike <br /> <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.o LI NIT IV <br /> <br />F-R 2005 <br />WP <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work descri Q i rH€f1n.4 <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County <br />WELL Location l2-'' N IA) so vs 1&) , Cross Street C. f4ztA115 City 7,f'-oc-k...fo irk Zip 15205— Parcel# <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 1ST <br />.1 61,7fe Environm <br />Ed <br /> <br />'Assessors <br />compliance with San <br />PROPERTY ,55 <br />Owner uo Address IS116 ..ceit2YIA( hkil City S6-.41-4 - Ft <br />,„ <br />Zip 90670 Phone# 5-6 2.9 z/ -35-8 / <br />C-57 Contractor 4)2 s(--- ii-AZ-t^^4,4"Dr:(I ins) Address pi 4 E. 164 i-e t I itve_ City dhAitei'm Zip7290S-Lic#8/ /3-Y8Phone# 7/4/ 9 39- 681 5 <br />Consultant / Sub Cntr 64o 14 C..-5 4 11-1`Address 315-101-Ift.; 1E5c.Lic# Phone# 7/ 1(% 6 - 5-333 <br />GIS Coordinates: X , Y , Township I IAJ Range <br /> &ea-51- <br />WORK TO BE PERFORMED: <br />El NEW WELL! BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, 0TH 'DESTRUCTION (choose type below) <br />a SOIL BORING # ryil'OVER-BORE. DIAMETER e.,,, <br />lir.WELL # Vv% l.,.. - .-5" a PRESSURE GROUT <br />a *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS „, <br />MONITORING X-IOLLOW STEM DIA. OF BOREHOLE i' [] MULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA: 2..” c,-) <br />a EXTRACTION [1 AIR HAMMER/DRIVEN CASING THICKNESS 5_ (.. YO TYPE OF CASING: [] STEEL )PVC [] OTHER: <br />[I VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 0- /g e TREMIE TYPE TO BE USED: [I AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE [I PUSH POINT (GP or CPT)GROUT SEAL PUMPED: G Yes f] No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0SOIL BORING a HAND AUGER GROUT SPECIFICATIONS 49,„(-44.4.....,( <br />, OTHER: 0 OTHER APPROX. BORING DEPTH t iO / 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 that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rul and Regul ns, and all applicable California State Laws. <br />Signed x G Title/Company 14 nc- A e)-47 e <br />Print Name - I/0I Date 2-4,0 <br />DEPARTMENT USE ONLY <br />Z AL a/G-4eAt_ &A-a7 Sq.-- <br />Well Permit Application <br />Section <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: A,jiI z...06S1 <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE ---------I-- # INVOICE <br />35b 2- IND 60, 10 1 Ig 1 Cz z- sR# ww/i12. , <br />C-57 WC N7TWAIVER C-57 Letter of Authorization to sign permit E c. açhment doc <br /> <br />El-ID 29-02-001 <br />6/22/04