Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMIRT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> - Telephone: (209) 468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> r <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 /> 5-31 N UJ C- -/w"-r4k; w.� c - Assessors <br /> Well Location CR go<.YAJ WE67oa1 5L Cross Street MAW-fNIS / A040 City 5Toc.K7a n/ Zip �S,ZOG Parcel# 16'/-XU-al <br /> Property T"^ irK /m,E2 52SY <br /> OWnerLbL L -SKr✓LAI- WEsm,IJ LLCAddressZ392 01025E "6 City fRUln/fJ LA-. Zip 926/y' Phone 7 <br /> C-57 Contractor tl-AIPAQ3 EN <br /> Am4-,yMl4-✓1Address 09 <br /> P66 43 city 04ybu.F_,�A zip 9S9G L ic#7 UG z u l Phone <br /> Consultant1Sub Cntr3u0-A4A IfW1i4 AddressG`l.'!U City iPLF,45,w7cr�/ Lie# Phone ?257-Y2G-Z67g <br /> GIS Coordinates:X-17f 17 q1 ,3 ,Y 3 < 'fI ,Township Range Section <br /> W RK TO BE PERFORMED: <br /> '9NGW­NELtiBORING(CPT E PROB HYDROPUNCH,HAND-AUGER,OTHER-) ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# 3 To 2a 3 w S ' G6 S ❑ OVER-BORE DIAMETER <br /> ❑WELL# y ❑ PRESSURE GROUT <br /> [I*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: Z6-r6Vk &IL" 1).97.f [5- -�ri n7F- 19, ZkJS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLEA 15 " ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS tJA TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes CI No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS C g4,- <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH P'a FFA 645 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifimtions in mmment sedion) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby certify at I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,Knd all appli b e California Laws. <br /> Signed Title/Company SR. GEOLOCoty/ - aUr2F�ApL( U.�Qf n9-S <br /> Print Name '3O Aj4L-I) Aswrerxy Date G-, 0 -ora <br /> 2 DEPARTMENT USE ONLY �--/ <br /> SITE MAP IN UNIT IV FILE,ADDRESS/ q: S31 <br /> WORK PLAN DATED: �6 / �7 C` <br /> APPLICATION ACCEPTED BY / ( DATE ISSUED oZ c3 d a AREA,p�7�)) <br /> GROUT INSPECTION BY ulYl FINAL INSPECTION BY DATED I U <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> ado f3D7666� TSI zz u sR# Y9/7 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5ID7 WELL PERMIT APP <br />