Laserfiche WebLink
kAT•SAN JOAQUIN COUNTYENVIRONMENTAL HEALTH DEPARTMEfI600 East Main Street, Stockton, CA 95202-30uuAG,ON <br />Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siqov,.QreDd UNIT IV <br />WELL PERMIT APPLICATION ENVIRUmvjENI HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE I IT/SERVICES <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. <br />n� Assessor's <br />I <br />Well Location �� S H ; r c7.), k kt Cross Street St, 0A City 7toC k c Zip15 C)G Parcel # 1 7 7 - a K©^C7 y <br />Property • �1 f� n �y L, <br />Owner Eli A r�.�l'N<<i'�tk j �'�°• Address -!oQ c (�1aKGJr lvg City h`1't}hc< Zip CA Phone #6( IG -36q 13a% <br />C-57 Contractor wec f 5 },:�, SL,,V I n� Address Q36 5 U.: ; ` M Dr City S+ac k-yA Zip qb-C Lic # 63 6 3 7 Phone <br />-� n <br />Consultant/Sub CntrbT I IL Address( -77'7 1y (,. (.E-rnt- +314 City�V"tLnAU,.L-, Lic# Phoneq�5 '`'1 l%_ G 6�g <br />GIS Coordinates: X 37-. ''Y "y_ (. 24F Township Range Section <br />WORK TO BE PERFORMED: <br />AID # FAC # <br />PE CODES <br />NEW WELUBORING (CPT, GEOPROBE, HYDROPUNCH, <br />F1 SOIL BORING# <br />HAND -AUGER, THER*)❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />%���/Cn ❑ OVER -BORE DIAMETER <br />DATE <br />*9WELL # S 4.c ll 5� <br />❑ PRESSURE GROUT <br />2 •0 <br />❑ *OTHER <br />/Y/ GROUT SPECIFICATIONS <br />O <br />age <br />69 <br />❑ EXPLOSIVES DETONATING CARD <br />`v <br />COMMENTS: X !! CX i ,,, �?,- (n -C -11S <br />CQ <br />a 6 r` CQ,a.r.c Ile— we (& r� 0cci1 *0 0 Ve c } S <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SP CIFICATIONS <br />MONITORING HOLLOW STEM <br />DIA. OF BOREHOI ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />[IEXTRACTION [IAIR HAMMER/DRIVEN <br />1Z <br />CASING THICKNES ChLl 0 TYPE OF CASING: ❑STEEL X PVC ElOTHER <br />[IVAPOR [IMUD ROTARY <br />DEPTH OF GROUT SEAL;L5' Ft{"( -l- TREMIE TYPE TO BE USED ❑ AUGERSX'HOSE <br />❑ AIR SPARGE/OZONE ❑ PUSH POINT (GP OR CPT)_ <br />GROUT SEAL PUMPEDYesJ*i (NOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />❑ SOIL BORING ❑ HAND AUGER <br />GROUT SPECIFICATIO <br />❑ OTHER: ❑ OTHER: <br />APPROX. BORING DEPTH 6 BOLTED TRAFFIC BOX OR ❑ S OVE PIP <br />CONDUCTOR CASING PROPOSED 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 I accordance with San Joaquin County Ordinances, Rules and <br />Regulatio and all applicable California a s. <br />_ <br />�� <br />041 <br />01"4­, <br />Signed <br />Title/Company r cX <br />--�� n <br />Print Name �) �°I��S f`►'1e <br />Date )-Ci I DC) LU <br />DEPARTMENT USE ONLY <0WB-UST 2,9,57- <br />9-S7- <br />QeZ ;• 00 �� <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />SITE <br />WORK PLAN DATED: <br />D -9-c- D ri <br />uW AREA o6 <br />APPLICATION ACCEPTED BY <br />_ . DAT3 1,6 <br />GROUT INSPECTION BY <br />FINAL INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />DATE <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY: <br />AID # FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED CHECK # RECV'D BY <br />DATE <br />PERMIT/SERVICE # <br />INVOICE <br />2 •0 <br />1� <br />99. 2s 36 <br />age <br />C-57 1V WC 1/ -WAIVER <br />EHD 29-01 10/28/09 <br />C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC AqA�_� <br />WELL PERMIT APP <br />