Laserfiche WebLink
• 0 <br /> `.;:.. ., <br /> SAN JOAQUIN COUNTY <br /> �. <br /> :�V RONMENTAL HEALTH DEPARTMEN <br /> 600 East Main Street, Stockton, CA 95202-3029 MITI: ,1- <br /> ' ) Uh iT <br /> Telephlune: (209) 468-3449 Fax: (209 468-3433 Web:wvt/w.slaov.org/ehd — <br /> 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. Assessor's 1 D -03 3� <br /> � ,i=t Zip Parcel# l <br /> Well Location�� r 0i+ Cross Street J I Wit/ City, <br /> Property r� aj ,�Sei6 �Ir i r:� —' Zip ! Phone 7 Cls —2 ?G <br /> Owner 441 ar i'�k'Cii�1;F 'c rUl Address _ City �s <br /> ' I f <br /> yr'"� T"�Yy� y `y�P �nv�� City�(iS�('�E,l�.. Lic#��T��ci�hone���"'���'��tE V <br /> C-57 Contractor. t Address i <br /> /�� E <br /> O" Address rG 'I ' �t0`7 ''�i t City 'i= �"� -' Lic# ��t Phont i <br /> - <br /> Consultant/Sub Cntr `° <br /> . j � � 7 Range Section <br /> Township <br /> GIS Coordinates. <br /> WORK TO BE PERFORMED: DESTRUCTION(CHOOSE TYPE BELOW) <br /> NEW WELLIBORING(CPT, EOPRO \,HYDROPUNCH,HAND-AUGER,OTHER-) ❑OVER-BORE DIAMETER <br /> F SOIL BORING# ❑PRESSURE GROUT <br /> ❑WELL# GROUT SPECIFICATIONS iW- <br /> ❑*OTHER [fly ^w} 611J I r <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS � il, r TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER r <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL I Q "-C7 TREMIE TYPE TO BE USED❑AUGERS❑HOSE Aj - <br /> ❑AIR SPARGE/OZONE ,PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:ElYes!01o (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ATIS'OIL BORING ❑HAND AUGER GROUT SPECIFICATIONS [[ `` � <br /> OTHER: APPROX.BORING DEPTH 4 V ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> ❑OTHER: ❑ C NDUCTOFrCASING P`�OPOSED if YES list specificationsin co�^ment section) <br /> t C t `t J1`1 '— �f r h6'��i rJ3``R� E "gV-1f L-5 A <br /> � <br /> COMMENTS: LI-C) I , <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify it I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, n at a p'cable f'alifornia Laws. F / ( f <br /> ,� Title/Company `/"� fGE^ (`n E rt<I lCE�F G Jc —7� <br /> Signed / �/"� ' <br /> r Date <br /> Print Name --- <br /> (� DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> 4 o <br /> APPLICATION ACCEPTED BY DATE SSUE 4i 1D-► I6 R -j <br /> GROUT INSPECTION 2 <br /> BY FINAL INSPECTION BY DATE <br /> N <br /> DATE FNVII�Ot}hII�ENT nUT�I <br /> DESTRUCTION INSPECTION BYR [ <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INF AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> DOC <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN ERM T ENCROACHMENT <br /> _ WELL PERMIT APP <br /> EHD 29-01 11/5/07(WEB) _ <br />