Laserfiche WebLink
p0 �� <br /> X00. `"•._� San Joaquin County `C cou <br /> Environmental Health Departments SITE <br /> 600 E. Main Street, Stockton, CA 95202-3029-<�- . <br /> G .VIITIGATIDN <br /> ' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov or {er UNIT IV <br /> rk°" ' 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 7pliE, on 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 /> Wy N� 1 JJ ,, y r; p�L�-yy7']Asscel# <br /> WELL Location �n,,�� p�Cross�Street �J�� ��/C✓Cit /� Zi J,� parcel# L.�DUI <br /> PROP <br /> TY <br /> OwnnerE(/Nldl1(INClf (1hM Qi Address & 049M 1City/'a(Aka Zip 3Phone#�ID•891� 2 <br /> C-57 Contractor ((,/hl Address Z20 / �[ City Zip 7 (�Lic# Phone# 90 S3Z ? <br /> Consultant/Sub Cntr SAIL Address W 1* Cilyai6/X*/ Lic# Phone#�)-qd&']//q <br /> 7 q o I 11 <br /> GIS Coordinates:X 3! y I,/ Y-1212 7 R Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/ BORING (CPTEOP OB HYDROPUNCH,HAND-AUGER,OTHER') p DESTRurnn. <br /> 0 SOIL BORING# 1 Y -7 0 O\ <br /> 0 WELL# 0 PR t) �t `/ <br /> ea'- <br /> a-Other GRO {Qt 1, T <br /> COMMENTS: N �'-,/t�\(tiY� �S — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> C� <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS ALP, __ __ <br /> 0EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASIP <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING j(HANDAUGER GROUT SPECIFICATIONS <br /> 0 OTHER: -7 0 OTHER APPROX.BORING DEPTH // 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 nc , R nd Regulations, and all applicable California State Laws. <br /> Signed Title/Company <br /> UPrint Na ! Ti � AbDate_6 yo� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDR SS: 253 Z Zjo2K �d y <br /> WORK PLAN DATED: ^ '2532- <br /> 200C / (y <br /> Application Accepted By Date Issued (o���� Area �b6 <br /> Grout Inspection By _Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> MID SR# 00 51 0 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit Encr rnent doc_ /// <br /> END 29-02-OOlweb ��/�A�2...� <br /> 6ND2 _o__ - <br />