Laserfiche WebLink
A � a <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax,(209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or Instal the work described. This application Is made in compliance with San <br /> Joaquin County Dttevelopment((Title.chapter 31115.3 and the Standar a an Joaquin County Environmental Health Department. <br /> WaN Locatlo;Sj V It.). nV51*' f� Street 9t city t Zip Q 1 Parcelso>'s �- <br /> Owner o Address I �� �ProportA �P I City Zip 990 Y Phone# �3� <br /> C-67 Contractor()i1b r � Address C City Zip�lJc# t�wne 13-� <br /> donsuttanVSub Cntr A6-i • Address q -1 94 City f7 Lic#4d ''73( <br /> GIS Caardinates:X Y Township Range Section <br /> TO AE PERFORMED. <br /> NEW WELt1BORIN 1(CPT,GEOPROBE.HYDROPUNCH.HAND-AUGER,OTHER") ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> WELL# MLo- _ [1 PRESSURE GROUT <br /> [I'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF INPE20§IRUCTION SPECIFICATIONS <br /> XMONITORING HOLLOW STEM DIA.OF BOREHOLE 'Si [3 MULTIPLE CASINGS 13MULTI-LI�L WELL CASING DIA:P <br /> 0 EXTRACTION ❑AIR HAMMERORIVEN CASA ING THICKNESSC3,'lo TYPE OF CASING:❑STEEL Q<PYC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL I 5 TREMIE TYPE TO BE USED 2AUGERS❑HOSE <br /> 0 AIR SPARGEIOZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:K, Yea ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS <br /> ©SOl1.BORING ❑HAND AUGER GROUT SPECIFICATIONS 10 fi <br /> 0 OTHER: ❑OTHER: APPROX.BORING DEPTH XBOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED--- SAID _ (if YES.Ret apedti moons in 0wowd no") <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHM E I <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I tmeW certify that I have prepared this appitoation and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Rew1wons,and all appllbte CaiN wnla <br /> s TitlelCompany P al / #� <br /> 7" " <br /> Print Name �� f /yl�✓► Date-- IS (� <br /> DEPARTMENT USE ONLY Cz <br /> SITE MAP IN UNIT IV FILE,ADDRESS: fr k1• a o Zcp S V ••v <br /> WORK PLAN DATED: JAN 1 5 2009 <br /> APPLICATION ACCEPTED BY DATE ISSUED <br /> GROUT INSPECTION BY I�tS,��,t*>� FINAL INSPECTION BYFRAUt >s Z O'� <br /> DESTRUCTION INSPECTION BY DATE 1 <br /> COMMENTSICONDITIONS• <br /> ACCOUNTING ONLY: AID# PAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECWD BY DATE PERMR/SERVICE# INVOICE <br /> L0v°o Zg�y� G.Q 1�Ze(o9 SR# S 6335 <br /> CvT WC -WAIVERC57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EFS 2"i 1116107 <br /> WELL PERMIT APP <br />