Laserfiche WebLink
r <br /> �b 5 <br /> °1 San Joaquin County <br /> Environmental Health Department SITE <br /> 4 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> r a Well Permit Application <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. 1�1 ���- i <br /> 15�14O JjL.,u� I0J' Assessors <br /> WELL Location�34:aC) Mc I<vi 1,i.i five Cross Street -L;,4- City L- V-��m Zip ` 5 350 Parcel# I b--060 7 <br /> PROPERTY <br /> Owner O � r"t��s Address J-7),�7 S i� -�»" Uity L-ra M _Zip q,5,3 Phone# ���I� —9�5 <br /> -61 <br /> C-57 Contractor \I'C W D-A kli nl Address ?,C- ?I," City`!_51C 1✓\ Zip 15'6i4I Lic#���""Phone#6�146 177=Lit 00 <br /> i <br /> Consultant/Sub Cntr f Y nLl Address f O N a c-aC4 9?vj City eCLC Lic# Phone# ''')t f? (J[7/t <br /> a$e t <br /> GIs Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 'PEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> '(WELL# ft r^04 14 tomj �Z W�r-1 0 PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS J� tip <br /> )MONITORING AHOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS">try 40 TYPE OF CASING: 0 STEEL ; PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL .a I TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 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 0 BOLTED TRAFFIC BOX or jkSTOVE 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 Regulations, and all applicable California State Laws. <br /> Signed x �" Title/Company N G et p <br /> Print Name C-° Date �17I /� j <br /> DEPARTMENJ U <br /> SE ONLY N-V <br /> SITE MAP IN UNIT IV FILE, ADDRESS: �val <br /> WORK PLAN DATED: 4?a,tja ( r c� <br /> Application Accepted By Date Issued ! ��t0'� 5 a <br /> C <br /> Grout Inspection By Date Final Inspection By , ,nAQ� <br /> Destruction Inspection By Date Er1VtRON ARTME <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EI-ID 29-02-001 <br /> 0/22/04 <br />