Laserfiche WebLink
Date <br />RECEIVE] <br /> <br /> <br />ORIGINAL <br />San Joaquin County <br />NMENT HEALfilivironmental Health Department <br />IT/SERK1110 East Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />e). k Well Permit Application <br />,I NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <br />AO; off <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 comliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />WELL Location 44K 3 •-)CA.L..) ---Koo.-8.. Cross Street -T-e_er,-.() rt+ City S+1)C-k-413n Zip C15215 Parcel# 1 L4- 32,4,0'07 <br />erectessill ate/e0 City Zip <br />1 <br />Phone# <br />PROPERTY <br />C-57 Contractor ea......a.ae --r).1.‘ \V rIcl Address 3(02.. Lyvtcs.._ ektc_k_. City Cervias.10- Zip (6-1(12.Licit 7-16iClPhone# 9 Ito - 6038-11109 <br />Consultant / Sub <br />Z4 E , Township Range Section <br />Cntr.b...3,-/c0,_ OSZPC‘Std 0-13,4-S Address citJ;2) CY*.Rick,vbr. City Pr‘ Lic# Phone# SU -34? —S 41-4/ <br />I ScSi-k'l10 <br />. 9 7? 5 ..• . '-0 9 GIS Coordinates: X .33% 1-8 , Yi-2_ I <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />SOIL BORING # <br />WELL # rn LO - 15reN rnu3- 1st) <br />*Other <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS . <br />I MONITORING I HOLLOW STEM DIA. OF BOREHOLE cd' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 02 _ <br />0 EXTRACTION 1:1 AIR HAMMER/DRIVEN CASING THICKNESS 40 TYPE OF CASING: 0 STEEL I PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL (o " TREMIE TYPE TO BE USED: I AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER:0 OTHER APPROX. BORING DEPTH -70' -, (55' i 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, Rules and ge ulations, and all applicable California State Laws. <br />d / : - <br />Signed x (---tx--( /'' - A ucce i..A: _lx,e------- Title/Companyrii or Nnsultio-l-plia a)nso 1J-0 rri- s <br />Print Name 61'a ir) oe, A lioelem Date /c,-. 4 <br />DEPARTMENT USE ONLY <br />tie O Va44/ ,-.7 /, al-- <br />jj DESTRUCTION (choose type below) <br />0 OVER-BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br /> <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date Issued — <br />Date Final Inspection By <br />Date <br />Area A61'1 <br />COMMENTS! CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# ( 5-Ke)06—i/57q71. <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE F".'ZFIMITtSC—FPAGE-REect INVOICE <br />34°1 eAll g 7-19V <br />.,„ <br />3g 31 AV717.6177 <br />C-5-77 WC WAIVER <br />EHD 29-02-001 WEB <br />9/11/2007 <br />C-57 Letter of Authorization to sign permitV Eioceeratnent doc <br />daft44—•--41=7: