Laserfiche WebLink
San Joaquin County <br /> `' t` Environmental Health Department SITE <br /> h <� <br /> 600 E.Main Street,Stockton,CA 95202-3029 MITIGATION <br /> ;> (209)468-3449 Fah:(209)468-3433 Web: www.sjgov.orglehd UNIT {V <br /> Well Permit Application <br /> e��Yruh� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin Cdunty for a permit to construct andlor install the vrak described. This application Is made in compliance vnth San <br /> Joaquin County Development Title,,Chapter 9-1115.3 an Standards of San Joaquin Co my Enwo n Health Department. <br /> �I -(� �?ASSeaso rr.o�y 7 <br /> WELL Localion r Cross Stree ty Zip j P=s# <br /> PROP TY / <br /> ome Addle a ! to Phone# rY 0 <br /> C-57 Contractor , ¢ less! S � J�CitY �+�fr ' ZiP�j Lic#� O���honek S'67�8�7 <br /> Consultant I Sub Cntr� f r'�Addres / t7Q h Lic#^�Phona-9& 9�Lkr <br /> SUi 100 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,XNEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BOFjIQIG -f. 0 OVER-BORE. DIAMETER <br /> �WELL# r"1 fit�,,a w.222Et"$ 1]PRESSURE GROUT <br /> `Othw _, GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE$+L 0 MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA Z t J <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS rl TYPE OF CASING: 0 STEEL WPVC 0 OTHER: <br /> B VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL IV TREMIE TYPE TO BE USED: �,At1GERS d6iOSE <br /> 0 AIR SPARGElOZONE 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 (>ot�,rwi}_ C yam,, &—t <br /> 0 OTHER: ___n OTHER APPROX.BORING DFPTH O r 0 BOLTED TRAFFIC BOX or 8 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: S2XU�1eL (r i�W ` <br /> t'-oy,iLL a� ar6g-4.- SG.f..cun1 f v _+u <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I h re certify that 1 have prepared this application and that the work Will be done in accordance with San Joaquin <br /> Co ty O loan b„Rules and Regulations,and all applicable California Slate Laws- <br /> Signed `1\ ruelconpany <br /> Print Na Date 00 <br /> _ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted Date Issued 1115-/ J 0 Area <br /> Grout Inspection By e _ —Final Inspection By -T ate 'Z`tom- <br /> Destruction Inspection 8 Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES PpEpE INFO AMOUNT REMITTED I CHECK# RECD BY DATE/ PERMIT!SEER/V�ICE REQUEST# INVOICE <br /> o 5 l-' 8`i . o J Z(SI SR# 5b_ l <br /> C-57, WCr�-WAIVER` C-57 Letter of Authorization to sign permit�ncroachment doc_ <br /> EHO 29-02-001 web <br /> 02103 <br />