Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ( t SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> P Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.s'gov.org/ehd UNIT IV <br /> SFO <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 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 /> Assessor'sPelertation }ZO N, � )oCqdp Cross Street Lqity�2S} c� Jvi <br /> Property <br /> 66m Parcel# IZf7_/030 <br /> Owner-J(d OI A-Deidt- S Address 80ygS- / Lcity &rfOv1 ft <br /> Zip �o8/D Phone# 70,x. S6S ORs <br /> C-57Contractor Test 441g6ho Address 3m, ltj)UN nf. City'�cg4 r�t0 eorr/ovi. Lic#914 SY9 Phone 916. 6 3 t SSby <br /> Consultant/Sub Cntr Qnrt¢,1/ a- Rovsrr�.Address y70V UOl�is E S)''r. City' L. i l Lic# "Phone S10.920,33W ' G � <br /> GIS Coordinates:X ,Y -, ,Township Range. Section 1 <br /> )WORK TO BE PERFORM Ifpi <br /> $[NEW WELL/BORING CP ,GEOPROSE;HYDROPUNCH,HAND-Ay�,OTHER'r#p OW-•{)E,.� ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# CPT-! GTP- Z $ CYT lSJ aw�r",� ❑OVER-BORE DIAMETER " <br /> WELL#'MW-� A 1AW- f — - El PRESSURE GROUT <br /> 'OTHER GROUT SPECIFICATIONS <br /> COMMENTS:�W rt 60r I S' w/CPT- <br /> TYPE OF WELL INSTALLATION TYPE - CONSTRUCTION SPECIFICATIONS " <br /> GP72' <br /> (T MONITORING 1G a 14 HOLLOW STEM DIA.OF BOREHOLE IO i n. LJ MffnI E CASINGS❑MULTI-LEVEL WELL CASING DIA: Y'11111, <br /> ❑EXTRACTION ❑AIR HAMMEWDRIVEN CASING THICKNESS&A. Ho`RUC TYPE OF.CASING:❑STEEL PrPVC ❑ OTHER <br /> I <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL''TREMIE TYPE TO BE USED tiff AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE $I PUSH POINT(GP OR PT) GROUT SEAL PUMPED:❑Yees.N No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') , <br /> In SOIL BORING Ir 3 ❑HAND AUGER GROUT SPECIFICATIONS F 1.1.1A <br /> ❑OTHER: - "❑OTHER: APPROX.BORING DEPTH 06l ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> ( CONDUCTOR CASING PROPOSED (if YES,list speufic tpons in comment section) <br /> COMMENTS: IS aF we j4"e in Sr A irk oar ) -Aouf- d�,�'h �p f ! � horn• X9'1 $. rdroµgdk ly. sa k C 'j• <br /> &CA rkIt WAY icJican/ w/a /oakY CAP 4UII a frtFfrc• rqf<d.id/ box, bO^f't1r, <br /> NOTE: OFFSITE BOWNGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT.PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 'I' I <br /> 1 hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> Signed J�JtA,u y,N ROd6.1e go Title/Company /WI7" �O�i jy /eDNPcfTJaa— t�ouvnr$',A-S'J©[id tcp j <br /> /� h t t <br /> Print Name L-NfNjp,L,1 KO,{/�;ti rre} Date�pVfnM <br /> U" DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Dor,%16> y <br /> WORK PLAN DATED: (> " A ' i ba- �`,t0 t A 1 <br /> APPLICATION ACCEPTED BY DATE SUED ►t. '� a a AREA ] 1 <br /> GROUT INSPECTION BY FINAL INSPECrTION BY �L DATE -I'L JX l4 ' <br /> DESTRUCTION INSPECTION BY 1 "�, I`r5�{.= ,.,lei.. - DATE f i'` TJ�' <br /> _ <br /> COMMENTS/CONDITIONS: I <br /> i, <br /> ACCOUNTING ONLY: AID-# FAC# \ <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY JDATEE PERMITISERVICE# INVOICE <br /> gat ��.�� g�.o7 �oSoZ o3 SR#ss°lA�•-' t <br /> C-51 14 WC Z -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN P RMT < ENCROACHMENT DOC <br /> EHD 29-01 1115X7(WEB) - WELL PERMIT APP <br />