Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ,Gf ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> MITIGATION <br /> I 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www sidov orcttehd <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRE 1 YEAR FROM DATE ISSUED <br /> cation is made in compliance with San ` <br /> �IT,1- 01\0 <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This app <br /> Standards of San Joaquin County Environmental Health Department, Assessor's.., Ilc <br /> Joaquin County Development Tftie,chapter 9-1115.3 nd M ` city f�1r,;l-( Zip _ Parcel# j <br /> Well Location ��;�) C) ��hi�42941let — -CIS -Zlt <br /> 1 � Zip a��;`Phone# _ _ _---- <br /> Prope1tY't} �11Z't 1� Address O 41 11 l Y7.� – City_{ �1 •ji 3 `� Q� <br /> Owner ( c. O+ Phone <br /> (()) H�%f l fl[F-- zip 5 5. Lic#4, �i <br /> Address�i 5 r Il..r ,v K� city--------- <br /> C-57 contractor Ur t 1� 1 'Wand Licit - Phone <br /> _ rctn v City - 75 �5� <br /> L t Address( ection <br /> onsultan ub Cntr ----- 5 e �C�._ Range <br /> GIS Coordinates:X <br /> Y ,Towns Ip <br /> WORK TO BE PERFORMED: Old DESTRUCTION(CHOOSE TYPE BELOW) <br /> NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH-HAND-AUGER,OTHER') RESSURE GR �''~ L'' ++I> 5:Mf< <br /> ❑SOIL BORING# "'"'' I <br /> ❑WELL# c GROUT SPECIFIGATivi 7 <br /> ❑`OTHER <br /> t firlar<< kAf <br /> COMMENTS: 11C 1 <br /> INSTALLATION TYPE CONSTRUCTION SPEECIFICATIONS rr <br /> TYPE OF WELL DIA.OF BOREHOLE 8" ❑MULTIPLE CASINGS 13 MULTI <br /> WELL CASING DIA: <br /> MONITORING ��FIOLLOW STEM <br /> 41D TYPE OF CASING:❑STEEL PVC ❑ OTHER <br /> ❑AIR HAMMERIDRIVEN CASING THICKNESS�,��t HOSE <br /> ❑EXTRACTION DEPTH OF GROUT SEAL • TREMIE TYPE TO BE USED AUGERS <br /> VAPOR ❑MUD ROTARY-- r <br /> GROUT SEAL PU Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH is 30) <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)__ L � <br /> GROUT SPECIFICATIONS n12(" CS11, <br /> ❑HAND AUGER '� ��� <br /> ❑SOIL BORING �y� BOLTED TRAFFIC BOX OR ❑STOVE PIP <br /> ❑OTHER: APPROX.BORING DEPTH I „t YES,lis sp i�nons m comm`pt j actwn) c� <br /> ❑OTHER: - . .�W CONDtjCTOR v SING Pr ROPOSeo ... t t� <br /> COMMENTS: r1LIIn1 6"AAI <br /> eatou+ <br /> NOTE: OFFSITE BORINGS REQUIRE ANOTICE SQUIRED ORTNSPECOR NONOACHMENT PERMITS �' yeu. � <br /> 48 WORKING HOURS fo�1� <br /> I hereby ertffy)that I hav''e'((((- epar d this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulati1� �and all app1ca le G Iifornia La ti <br /> V �, <br /> Title/Company <br /> ^ <br /> Signed Date 46 <br /> Print Name )r ���� rC <br /> r DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> \ <br /> WORK PLAN DATED: 11111111111111111,1111%'. �' �'�� (�l c0� AREA 3jN <br /> DAk1S6,2 <br /> D A`Ss ar TION ACCEPT D BY l m+w DATE <br /> PG ROUT�SPEC11IlOf�BY13 FINAL INSPECTION BY <br /> DATE <br /> DESTRUCTION INSPECTION BY <br /> COMMENTSfCONDITIONS: � – 4 <br /> FAC# <br /> ACCOUNTING ONLY: AID# RECV'D BY DATE PERMITlSERVICE# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# <br /> 4+4r"0 tool `I-15l11 S # SAAB <br /> -WAIVER C57 LETTER OF AUTHORI TI N TO SIGN PERMIT ENCROACHMENT DOC <br /> O(,tm,%s\ WELL PERMIT APP <br /> EHD 2}01 1,15107 lJ <br />