Laserfiche WebLink
mi <br /> lSan Joaquin County WLS��ai, Environmental Health Department WLS 15 E <br /> 304 East Weber Avenue, 3rd Floor, Stockton; CA 95202 AUG g MbfjIGATIGN <br /> 7' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd 11 N IT IV <br /> Well Permit Application ENVIRONMENT HE] <br /> PERMIT/SERVIUS <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 /> WELL Location 50D Cc'b"1 Louisr_ Assessors <br /> �v+� Cross Street City Lu-I'L roP Zip --153.�D Parcel# I`18-120-0(� <br /> PROPERTY ` <br /> Owner/�t�.�M!I/yrn Address SA=EsiST LOuyYE City Ts1 Zip9gT36 Phone# ZI—'96'8—(.290 <br /> C-57 Contractor Vf'j Ml U IN6 W Address f0 60X ttlb City L Zip 150kic#7.E ifPhone#IML 7�}�llCO <br /> Consultant/Sub Cn1fr6.Jme Ervin 7jSc.U"/kC..Addressft f' YW9['te�r. City tLJLic# Phone#(2dq)z3' -0SfX <br /> i <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/ BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER') g DESTRUCTION (choose type below). <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> ,WELL# - p PRESSURE GROUT - <br /> 0*Other � 1 II GROUT SPECIFICATIONS <br /> COMMENTS: 001V c)tstt'itoA i✓\ At�c(4r+uj MoAi' en4 ln)ill5 J�-ct5�ala+krA Ott-, PI-A— Ao1 1$rzoo5 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> KMONITORINGHOLLOW STEM DIA.OF BOREHOLE R r/ []MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z�/ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> p AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS_Tvd6 �� NEnT 49MrEA)T r 8&il. A.9 <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH N 2.6 7 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED AfD (if YES,list specifications in comment section) <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 in accordance with San Joaquin <br /> County Ordina ces, Rules and Egu ations, and all applicable California State Laws. <br /> Signed x Title/Company G55[�/f11LQ'ra/fT//Vvj&z 642J21 &s,LArY <br /> Print Name Date <br /> DEPARTMENT USE ONLY ;h 5 <br /> SITE MAP IN UNIT IV FILE,ADDRESS- 013 V <br /> WORK PLAN DATED: ����185 a'u'� .z DS <br /> Application Accepted Byrr �/"�`--7C8'lt�� ��_��_ ��/��I Date Issued Area <br /> Grout Inspection By (.(,.n.�..c rn.._ Date�Final Inspection ate �S''C] Ob <br /> Destruction Inspection By Date <br /> ll `` <br /> COMMENTS/CONDITIONS: 1V f <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> .2'707 SR# Ll3g3/ <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-00 t - <br /> 622/04 <br />