Laserfiche WebLink
.o San Joaquin County t%pl FILE COPY <br /> Environmental Health Department (�� (��� (SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 9520 ° M GATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehcbLC _ UuJ UNIT IV <br /> Well Permit Application <br /> BVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 /> / Assessors <br /> WELL Location /6 y7<7 ��...,`.:�e {�r.Le Cross Street 6.':" /1rr City ip 9-fitp0 Parcel# "96- 3fT0'--LZ <br /> PROPERTY <br /> Owner C,'-.Ie (t' r<s Address /G• &X CityAPe�Zip YP77 Phone# <br /> o 1J //";4 <br /> Ma..cbs 5742 <br /> C-57 Contractor Cfca•.�C !'w('�tr5 Adtlress .?�3z Owae c <<i-e� City cw-.Pmva Zipq Lilt 7/7510 Phoria# <br /> Consultant/Sub CntrS1rCOl' I frt*ativ/IAddress?O/7 <br /> y Phone# �6/ OSOO <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> p SOIL BORING# a OVER-BORE. DIAMETER <br /> [WELL# 1]PRESSURE GROUT <br /> a•Other GROUT SPECIFICATIONS <br /> COMMENTS:�i w-C rr•sfi^ux (qC se.rL. /.Ir /se/ai/�.r ��iei+rs�YySCd f r.�ivJ� �` f`S :i�'r /fir <br /> CUA: VH C'cS/hOi <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS n <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE_LL L E MULTIPLE CASINGS 1]MULTI-LEVEL WELL CASING DIA: <br /> p EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS=.. YD/teTYPE OF CASING: I]STEEL (PVC 0 OTHER: <br /> p VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL !S r TRI TYPE TO BE U ED: AUGERS D HOSE <br /> p AIR SPARGE/OZONE E PUSH POINT(GP or CPT)GROUT SEAL PUMPED: les 0 No (NOTE: AXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING p HAND AUGER GROUT SPECIFICATIONS 41en1F << <br /> r <br /> (]OTHER: QTH R y��•,,�APPROX.BORING DEPTH 7��r�BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �+�1W�s ��, �.�^' ;PMDUCTOR CASING PROPOSED Y S (if YES,list specifications in comment section <br /> C0 MIR ENTS: P 'r lf�`1H<���- 1f/e-y� H 4e�(z+i' !y vH .� /,t /4 l �f ✓ �3' /.� i� K <br /> /4 Core �fY� ✓�T �!i-fr •�/ -"Y'•S /J (' //AII�f/CiY 4'h "T l ,// 4 HSC% /G 41,,114" � <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITf <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 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 /> Signed x .Cl ¢: Title/Companyf �fo�s%Sf/�E C <br /> P — <br /> Print Name A��rrrf^ Date O.S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: �I LD <br /> Application Accepted By Date Issued �a �� Area & <br /> Grout Inspection By Date _Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 360 Itb 5 SR# VoqQ1v <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />