Laserfiche WebLink
SAN JOAQUIN COUNTY — <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> +/`. Telephone: (209) 468-3449 Fax: (209)468-3433 Web:WWw.Sigov�ro/ehd JEuI i IV <br /> WELL PERMIT APPLICATION Pr9`li,':/,cF <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 1115.3 and the Standards o Sa oaglp�in County Environ a tal Health Department. <br /> !I I„''a •C'• / ,r j Assessor' k /+► <br /> Well Location 6lJ l: ,tQ Cross Stree tALI S ((f111UUDgUU City Zip9 zf Parcel# !"CJ ' C1 <br /> Property c <br /> Owner IZ (a 1 VF' Address]q P oS (.(,,p��f Cc' `Or1 City Zip Phone# <br /> to a wF / r��- <br /> C-57 Contractor ( IN Address City ,a.!Y�c � Pho,f611I —' ii <br /> Consultant/Sub Cntr 18r Addresa0g] r City /fC Lic Ph,, <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> „ ❑NEW WELL/BORING(CPT,GEOPROB'e,HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> OIL BORING# ❑OVER-BORE DIAMETER <br /> WELL# ❑PRESSURE GROUT <br /> OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS yt <br /> ❑MONITORING HOLLOW STEM DIA.OF BOREHOLE n El MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: <br /> II <br /> ❑EXTRACTION El AIR HAMMER/DRIVEN CASING THICKNESS 1/16 TYPE OF CASING:❑STEEL APVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USEDVI AUGERS 0 HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS II OY�Lv j CJ/3.0,,h,t <br /> �L <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> tCONDUCT R CASING PROPOSED (@Y a,lists c'rfications in wm nt section) <br /> COMMENTS: r1t 14, y <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR E CROACHMENT 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 Count r Ordinances,Rules and <br /> Regulations, applicab L <br /> t <br /> Signed Title/Company/ IP •r / • c/ <br /> P <br /> Print Name -f Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1-S 52 D �(cs��N'�t'1'(. �[ �• <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED of AREA 1,( <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> LACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> V 12g, 1>0 '31 . L-0 3s'lAUTHORIZATION TO 2l to SR# C k <br /> C-57 WC -WAIVER C57 LETTER OF SIGN PERMIT ENCROACHIMENTDOC <br /> EHD 2&0111ISN](WEB) �ERMIT APP <br /> P/vW ool at '�i J <br />