Laserfiche WebLink
,-- <br /> ��n` SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 ` `' �' (1� SITE <br /> j `IJ 11yIITIGATION <br /> Telephone: (209)468-3449 Fax:(209)468-3433 Web:www.sidov oro/ehd <br /> _UNIT IV <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. <br /> ig4Wta <br /> 1nei <br /> Well Location , Cross Street W1. ��o (�r <br /> IJt ,C , 3J�( Assessor' <br /> Property C �ro CitY Zip Parcel# _V <br /> AV OF W <br /> - <br /> Owner SM Q Vt P Jcddress City StGCkfor\ C/k ZiPgjZ)S Phone -35f,) <br /> ) <br /> C-57Contractor Address 2Zj PfS� S�} city C/1 Lic#?02 � PhoneLo668-2C1L/ <br /> Consultant/Sub C <br /> Address IrJ?� /cwt S� 67S City Cl`f1c Lic# PIA <br /> Phone <br /> GIS Coordinates:X Y Township Range 9 Section <br /> WORK TO BE Pgff <br /> ®NEW WEL ORI CPT GEOPRO YDROPUNCH,HAND-AUGER,OTHER') El DESTRUCTION(CHOOSE TYPE BELOW) <br /> ®SOIL BORING# �= <br /> ❑WELL# ❑OVER-BORE DIAMETER <br /> ❑'OTHER ❑PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPEO <br /> CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE G q�/ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS 17j/} TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER Nil <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 70= OA?} TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE '®PUSH POINT GP R CPT)_ GROUT SEAL PUMPED:[I ElJ <br /> YesA No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> IR SOIL BORING HAND AUGER GROUT SPECIFICATIONS vc-4 CP-/"�+ <br /> C]OTHER: ❑OTHER: APPROX.BORING DEPTH 20-re&+ <br /> CONDUCTOR ASING PROPOSED ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: �P/`1r'J hr`Y � �+ ���� (if YES,list specifications in comment section) <br /> OSP �( U r)r Pr �)llO,Cj CE C1n pyo (Q! �OI/^��f G41L YE/ lOV 4�r 1J✓jD rt�/ 1� <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 /> Regulations,and all a piicable California Laws. //' f <br /> Signed /� Title/Company Fy)`eC-co C4 )oy,WAA_2 C <br /> Print Name slenn 6--e A ke— Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY ZDATE ISSUED Ct AREA. 7q <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE ll oY <br /> DESTRUCTION INSPECTION BY DATE ,A <br /> COMMENTS/CONDITIONS: 61Z'S I',t,O,Qit _ <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> V� $e7 - ��- ,,�� 1 h 64 SR#ao��!;_oq <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2M1 11/5!07(WEB) <br /> WELL PERMIT APP <br />