Laserfiche WebLink
ORIGINAL. <br /> WELL PERMIT APPLICATION FORM , SITE <br /> SAN JOAQUIN COUNTY ' <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EH ) y " MITIGATION <br /> 304 E. Weber, Third Floor, Stockton, CA., 9520 'p5�5 UNIT IV <br /> MAR 3 1 2003 (209) 468-3449 <br /> ENVit,UN.MENT\\'H(EASD laal" <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> O��CA L <br /> ApplicatiKahul&5WdA91n 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 /> Assessors <br /> WELL Location t+w'1 N E-i3avv.sD ont.-CL^rP Cross Street Fj,i35-4-T City Si�cy,-y04 Zip 4IS202 Parcel# <br /> PROPERTY Owner Address 1114t 8. C*VA97160L WA*Y City STbCX,i'D L Zip Phone# <br /> C-57 Contractor SF7-M+-4 Address 2365 wtC,--A4 n 02. City -Mcyj.0 Zip °tStUi Lic# 12 Phone# 20`I -1464 9i2 <br /> Consultant ISub Cntrl��,NFt ��-1( Address -46z.SE. rCrtntiE City S?oCAPO, Lic# Phone# 20r-t- 9ltk-13g <br /> GIS Coordinates:X 'Y Township I OJT Range 6 E Section I <br /> WORK TO BE PERFORMED: <br /> ,NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> RWELL# 0S21 3041,S (Ion &Ji ,.K">- 12 -4�-LS- a PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: fDv P- o:L-oaE SPAALc,% CSJM.►c` NOVA �� Ts t SP�.RA� Pat"-rS jr4S � <br /> Lr L f_A-<.aF n.;� Dt swl OF 3a` 6a' A--p4C\ ctu' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS K <br /> 0 MONITORING $,HOLLOW STEM DIA.OF BOREHOLE gMULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS >GH.40 TYPE OF CASING: 0 STEEL 0 PVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL73"315w#-j (.vsTREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> PIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: AYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS "t1.-i <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH cj,' dEt J (v.+ PGOLTED TRAFFIC BOX or 0 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 Ordinanc Rules and Regulations, and all applicable California State Laws. <br /> Signed x / Title/Company 5714-Ff 6-06-,K 2 I� .J f-E �E.(Z <br /> }��.!"_3 S—' 3 La- J 3 <br /> Print Name , <br /> DEPARTMENT USE ONLY Date <br /> SITE MAP IN UNIT IV FILE,ADDRESS: `L& Al- 1`t� 1 <br /> WORK PLAN DATED: cob�': — 03 C <br /> Application Accepted By Date Issued Area O � <br /> Grout Inspection By Date Final Inspection By Date 6 -1-7-03 <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/SERVICE REQUEST# INVOICE <br /> O, AW �� 3.31•x3 sR# 0C 6/0 <br /> C-57-1/- WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br /> /rCL*pt <br />