Laserfiche WebLink
WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> RECO EDD SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> JUN 0 3 2004 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENT HEALTH <br /> (209) 468-3449 <br /> PERMIT/SERVICES 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 Sa�ln Joaquin County Environmental Health Department.Assessors <br /> �'7a �/Alffyf+ �aN Cross Street Ca oM city M 'Vfg& Zip 9x33 Parcel# aoo -130-0/ <br /> WELL Location �/ L �// �A <br /> /"/f Ldirtsi-oDnerC(OMAddrass y'7 A114( Vef UA City /[4vfeee, zip9s33 Phone# sa3- SSS-/ <br /> PROPERTY Owner prf 530— jq <br /> C-57 Contractor EN Pre Address ���x�0F3 l� t' f/cii�ty city <br /> -1 I! � zi,P—tA-Lic# 7/'— Phone# of <br /> Consultant/Sub Contractor <br /> �/{, v l fa 1°�—Address 1 D a J L / '`f t*city (d 6=Lim Phone# 9W--(3 5 <br /> Y.,,Township <br /> J Range �O E Section <br /> GIS Coordinates:X <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') a OVER-BORE <br /> „`SOIL BORING# —$ 0 PRESSURE GROUT <br /> �W ELL# Grout Specifications: <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _. <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE .7 MULTIPLE CASINGS?BYES D NO WELL CASING DIA:_ <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS--=—TYPE OF CASING: 0 STEEL 0 PVC BOTHER, <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL �0 r TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> B AIR SPARGE O PUSH POINT <br /> SOIL BORING 0 HAND AUGER LL GROUT SPECIFICATIONS: N <br /> OTHER(, VC APPROX.BORING DEPTH a0 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: ---Pl-- if YES,lists ecifications here): <br /> CONDUCTOR CASING PROPOSED. (� P <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that 1 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 /> ��� j��ft/L� _ Title/Company <br /> s�a ��e, <br /> Signed x ,y Q <br /> f �a K/L^[$ /L F�eo PIt/ Date �O O <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: y } Z. at I <br /> WORK PLAN DATED: S 2-(o z oo <br /> �i{�. ^ ori Date Issued b/ g/�y �� <br /> Application Accepted By Z� <br /> Grout Inspection By <br /> Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# cera <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a9 $ �0'pO 12j tLk 6 cY sR. 28-Z, 2- <br /> C-57— WC_WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> 1/25/02 <br />