Laserfiche WebLink
FILE COPY <br /> WELL PERMIT APPLICATION FORM ENVI,4G�$lMAL HEALTH <br /> C� SAN JOAQUIN COUNTY °t=pM I&ATFON <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) 03 AUGU����4: Z4 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> Q <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> >ppliwlion is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. - <br /> �'j a Assessors <br /> NELL Location t00 �1�C L'� - - _ Cross Street C-44" "'r 66City C° Zip �"rP Parcel# NA , <br /> PROPERTY �, 1T Ar CAti � 16`7 `75 t'tvwL�M.a- LAnn "A 9S3-\O CZoS HS$-2K6oX 32! <br /> Tuner y Address City Zip Phone# <br /> -57 Contractor Address 3 L 1 Z OALZ C'ti J- City- Zip 9S*1Y 2-Lic#7 179"Phone# (Y 16�6 3 fr-f)6 9 <br /> Consultant I Sub Crit, Sl=�^� �..lc�.,,.+r'�-"Address 't h K lL6"`'! 10o City c1 '�° Lic# Phone# C 516�j$6)- by oo <br /> N M ,Y ? .Township �"r` Range "''f'' Section <br /> GIS Coordinates:X P 9 <br /> WORK TO BE PERFORMED: <br /> RMEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# I]OVER-BORE. DIAMETER <br /> If WELL# /`'1 vJ- 6 0 PRESSURE GROUT <br /> (I'Other GROUT SPECIFICATIONS <br /> COMMENTS: is cK po-`aFo<.�£D 1 n¢Gti..�..rcc �v (Z+S t�. ItwS)/6y7D C�r.rS,yog. 51.-rlc, L±-r�wa cd <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 2 MONITORING FHOLLOWSTEM DIA.OF BOREHOLE K r' a MULTIPLE CASINGS 1]MULTI-LEVEL WELL CASING DIA: <br /> ]EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS 5�'y`� TYPE OF CASING: 0 STEEL )$PVC ]]OTHER: <br /> ]'VAPOR a MUD ROTARY DEPTH OF GROUT SEAL t`S`r Z/ TREMIE TYPE TO BE USED: ^OAUGERS N HOSE <br /> ]AIR SPARGE/OZONE Il PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes M No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 9 S,:,-BORING a HAND AUGER GROUT SPECIFICATIONS <br /> ]O.:+ER: fl OTHER APPROX.BORING DEPTH Z S r &BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED '' (if YES,list specifications in comment section) <br /> -OwAENTS:-tkf wetL b r-L /i1 (r Perez' PWCr26 . toy '%c tw F,�S— r,Nc.l(.: (o-1 S')M.. SC .....5 S1,i 'Mx . <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> >gned x 1 /-� r ✓`"� Title/Company Pro3'r� Co�o51�. Sc w.c Z•fira.�i+i+J�-�I.K- <br /> Tint Name <br /> 'T-M,0/lArsY. OAAAx� Date 7�ZI �o3 <br /> DEPARTMENT USE ONLY <br /> 31TE MAP IN UNIT IV FILE,ADDRESS: ✓T <br /> NORK PLAN DATED: /nt <br /> 1pplication Accepted By t� Date Issued C Are V <br /> 3rout Inspection By Date Final Inspection By Date <br /> )estruction Inspection By Date <br /> :OMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35D1 -4 sR# <br /> -57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment dooc�_ 9/30 0.2 <br />