Laserfiche WebLink
d <br /> yRU �O SAN JOAQUIN COUNTY FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> �i 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 /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicata o San Joaquin County for a permit to construct andlor 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 /> �i w�..r�!;1 ,/ Assessor's <br /> Well Locatl n ,.(,r e0. Cross Street Yi�'a a �/e city ��� Zip <br /> 9s33o Parcel# 191-$So-0t( <br /> Property I C�G3 <br /> Owner_ _ __ Address /. - �city�Zipl�J/�� Phone#C4lS) 314^ x/o <br /> C-57 Contractor �W DriltGna Adtlress P•°• 6ox 970 City Lodi Lic#7Ai0.904 Phon�;o9) 369-9400 <br /> �— <br /> ConsultanUSubCntr EN&EO Tnc. Address $90 N. Wilma A*je city Kpon. Lic# N/Q_Phone( -9) 835-6610 <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED; a7.804 Lon. -121. 3)o <br /> I9 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑ SOIL BORING# ❑OVER-BORE DIAMETER <br /> SWELL# to MCJ RtPl.re..,...•F eF MWM-N) El PRESSURE GROUT <br /> ❑-OTHER GROUT SPECIFICATIONS <br /> COMMENTS: 5 wend L o d' will b p 6P sl, J -nyrlllr�i r+v. fr-p <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> X MONITORING CKHOULOWSTEM DIA.OF BOREHOLE 10-in. ❑MULTIPLE.CASINGS❑MULTI-LEVEL WELL CASING DIA 14 <br /> ❑EXTRACTION ❑AIR HAMMERIORIVEN CASING THICKNESS 614,, 40 TYPE OF CASING:❑STEEL JK PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 10. }• TREMIE TYPE TO BE USED I9 AUGERS❑HOSE <br /> ❑AIR SPARGEIOZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes %No(NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS bleak CGyn-w,, - <br /> ❑O7HER:_ ❑OTHER: APPROX.BORING DEPTH N +. BOLTED TRAFFIC BOX OR ❑STOVE PIPE - <br /> CONDUCTDRCASING.PROPDSED a (if YES,list specifications In wmmenr sectlon) <br /> COMMENTS: A4 ,al jei( Ce'.�5�-r++e�:� rail!�nu61;31,r1 '.i "'If re,,,-pl&ko B'aQ=,L- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 46 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> hereby certify that I have prepared this application and that the work will be done 1 accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all ap/pp cc , e lifornia Laws, <br /> Signed //////( �• Title/Company &a Ioars 16'V6'ro <br /> Print Name oc C-i-a W��d �P.G. Date 41161 X00 9 <br /> 'l DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: p•�1 <br /> ���`• �O e) <br /> WORK PLAN DATED:. �e`��"'�� "f- •V / <br /> APPLICATION ACCEPTED BY DATE IS ED 6 AREA <br /> GROUT INSPECTION BY FINAL INSPECTION �� �F.D DAT <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# REC 'D BY DATE PERMITISERVICE# INVOICE <br /> 'Oy 4 -Ib-O R#� 0 <br /> C-57 V WC V, -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD2Mi 11/507(WEB) WELL PERMIT APP <br />