Laserfiche WebLink
U1 SAN JOAQUIN COUNTY <br /> IRONMENTAL HEALTH DEPARIONT 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 /> 4�/FOPN _ <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 ConsWct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Develo mentTitle,cls ter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Pj Rd. Assessor's <br /> Well Locationl&i !,w(?=Y 4F Qd Cross Street W 1(1A-`5frr�t City T2LCL7 Cdr' Zip� Parcels# 250-IDD-1)77 <br /> Property p p. <br /> Owner, ) �A,psi 7C,,j Address Eb.WlB(� Cit �QN j0 a//J,�ip'93�F7D Phone# <br /> C-57 Contractor 6C*ICq% D^t1� Address 472&t0%L,, )6c Citv!51 . 1 4,11 Lic#4§IbS PhonerfZS-its-Slob <br /> c5it Ito <br /> ConsultanttSub Cntr U1$L5 Address 2b-10 Cswtewa,�Owlsbe-, ciilys,cvtmnfe Lic# Phone599-SR;-46Tc <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> JK NEW WELLIBORING(CP'J roOP408,E,tiY Tr6N4 i HAND-AUGER,OTHER') 0 OVER-BORE DIAMETER TYPE BELOW) <br /> SOIL BORING# lX cl (:.NU <br /> WELL# B PRESSURE GROUTC�rvte.KL-eL.wry <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA_ <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC 0 OTHER <br /> ❑VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGEIOZONE til PUSH POINT(GP ORI( _GROUT SEAL PUMPED:0 Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> JRSOILBORING ❑HANDAUGER GROUT SPECIFICATIONS Qc MND <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH-t91b' 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED IT YES,Iiolspedrralians ction) <br /> COMMENTS: <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 applicable California Laws. <br /> Signedl�nt'Ce/l. /�A,7 ydZ� — Title/Company Pieic�f'/Llry.....,r �Strnw6[D� is� �U�S� <br /> Print Name f' Glb( <e-A. ..Ms rev- Date <br /> r� DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORKPLANDATED: _G!/I'L- QCt3 GQ, <br /> APPLICATION ACCEPTED BY DATE ISSUED [ n� AREA 9`3,2 / <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE ( _ G/ <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMT REMITTED CHECK# REC7D BY DATE PERMIT/SERVICE# INVOICE <br /> D — 3 -z 0&L 14 1 SR#IROS 35_2 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2 111/5107(WEB) WELL PERMIT APP <br />