Laserfiche WebLink
• <br />• FILE COPY <br />WELL PERMIT APPLICATION FORM <br />910'Rofi' ZEIN* t,L HEALit! SAN JOAQUIN COUNTY <br />^1-,�1,T r' ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />03 DEC 15 PM 4: 0§04 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />d5r- om 5 <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. <br />Assessors <br />&�� / I�SCrossStreets!lrtt<orl <br />Sr City SYOCi<%ro✓1 Zip O6 Parcel# <br />WELL Locatior QjT L/0.y <br />PROPERTY <br />OwnerCaltE. 4CN11y 1U+1' Euard Address a9OD &dg!nE Rd City Sacr�a►«cnY ZiPg5fr2 Phone#%lb Q5Y' —3 60 <br />C-57 Contra ctor p1&`o /o Address PO ?OX 6C 3 City oV1 i�G Zip $q 966Lic#Phone# 5303��Z2�� <br />Consultant /Sub Cntr V e 1/'S a d" rl G . Address1ji�'1H /��Aci/So✓f /SVG Cityk�Lic# Phone#'tl6 863 q 3Z6 <br />Sulrle, <br />GIS Coordinates: X <br />Y ,Township Range Section <br />WORK TO BE PERFORMED: <br />XNEW WELL / BORING (CPT, GEOPROSE, HYDROPUNCH, HAND -AUGER, OTHER') <br />0 <br />SOIL WELLBORING # <br />(/G <br />0 'Other <br />COMMENTS: <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />it 0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE XPUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 1Ve9t7- Ct rr trnr- win S% b eNid"0 e, <br />0 OTHER:_O <br />OTHER APPROX. BORING DEPTH 4,17 FI— 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED NO (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, Rule::������Title/Company---Vc� able California State Laws. <br />l N G ! (/'O I•YG� / ' �' n y c'�' <br />Signed <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By_ <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITION <br />DEPARTMENT USE ONLY <br />a'y- <br />0 2— <br />Date <br />Final Inspection <br />Area I Q <br />ACCOUNTING ONLY:D# FAC# <br />PE CODESWIE <br />T REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST# <br />�� SI., io 10 �z • I sR# oo c03 <br />C-57_ WC_.= WAIVER_ C-57 Letter of Authorization to sign permit_, Encroachment doc_ <br />INVOICE <br />9/30/02 <br />