Laserfiche WebLink
WELL Location (-ION (44 co <br />PROPERIX <br />A Owner ldivt.4/Notrx rtOrlak, Address <br />San Joaquin County <br />Envi, imental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95p2i7pEGyEITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.ori/eh UNIT IV <br />Well Permit Application AUG 1 2005 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IStAlp t iloNmE <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work describell-p4 .fpp ..rTIL in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmerital Heatth) <br />N/6) Cross Street <br />836 <br />C-57 Contractor CC4..cr .,CLL Address % Otte.c., Cr) city c1JflO zip757P- Licil PC70 phonetegY3g -i/cy <br />Address '67 show, kdi City 4-CJe--ta-ILic# 6314?)) Phonek_YCC 5-11 -(gai Consultant / Sub Cntrk5-E <br />GIS Coordinates: X Y Township Range Section <br />W9RK TO BE PERFORMED: <br />ggslEW WELL / BORING <br />O SOIL BORING # <br />WELL # I W-12.kt UNA) 1.) 1114-C4) ) (A) -ct <br />City <br />5\12d44.04 zip 5)0 5.-Apsaszs4tor) 01 <br />.citysea,41-4 Zip qkflO1 Phone# VOST.5-7-14602# <br />a *Other <br />COMMENTS: <br />(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />a OVER-BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />INSTALLATION TYPE <br />.1+KOLLOW STEM <br />AIR HAMMER/DRIVEN <br />CONSTRUCTION SPECIFICATIONS <br />., it <br />DIA. OF BOREHOLE SIt 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS5dA 10 TYPE OF CASING: a STEEL li(PVC a OTHER: <br />0 MUD ROTARY DEPTH OF GROUT SEALC:01 TREMIE TYPE TO BE USED: ZAUGERS 0 HOSE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: IrYes 0 No (NOT: MAXIMUM FREE-FALL DEPTH IS 30') <br />D HAND AUGER GROUT SPECIFICATIONS 0615 P/4,0Y 6c.ilt ,r‘ 4..)efiev- I <br />0 OTHER APPROX. BORING DEPTH 48c‘ BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED <br />TY E OF VVELL <br />MONITORING <br />EXTRACTION <br />VAPOR <br />0 AIR SPARGE/ OZONE <br />0 SOIL BORING <br />O OTHER: <br />COMMENTS: <br />Ao <br />(if YES, list specifications in comment section) <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />ertan Adm4i <br />DEP ARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: (•%4 CA)a*c..\lcc, <br />WORK PLAN DATED: <br />Application Accepted By Date Issued <br />Grout Inspection By (A,-A.A4i•-•ct-s--v Date (g 130/0 Final Inspection By <br />5— Area 2-1 5 4 <br />(t. 1 0E, Date <br />lArk/vt"cr,v <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, Rules an1 Regulations, and all applicable California State 17?ws. <br />Title/Company 1V03-eCi-Gedi Signed x <br />Print Name Date 46/0s- <br />k.k.AA.Anc-c•-.....— <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# i <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE PE UEST # <br />i 5-0 I <br />6 .5-0 "( <br />Ifet .00 <br />..11-81.(-3° <br />u <br />444 A., glz4c5 S Rit 0-1 3gsko <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroac ment doc <br /> <br />EHD 29-02-001 <br />6/22/04