Laserfiche WebLink
FILE DOPY <br /> WELL PERMIT APPLICATION FORM , SITE <br /> SAN JOAQUIN COUNTY �y MITIGATION <br /> � i!f ENVIRONMENTAL HEALTH DEPARTMENT (EH )r 5,y UNIT IV f <br /> 2003 304 E. Weber, Third Floor, Stockton, CA., 9520 <br /> MAR 3 1 (209) 468-3449 �rF /� ��,Aa4c�o <br /> ENVIRUNM/,L�CN��TR\H'II(E(��,,AFFLSSI�� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 <br /> ApplicatiK6h&1&5 2dAYd"San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> i. Joaquin county Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department.A�sessors <br />�. WELL Location N E (Saw.+O ow—cUMP Cross Street F ,Xa A1.-t city <br /> �r-��� Zip 615202 Parcel# <br /> 4u.Ti2-ki-)S <br /> I�t36 C 4kQ"6'a-�1RY City «L,,--'O..I ZIP Phone# <br /> PROPERTY Owner Address f <br /> (f6S 412 <br /> f, Address 2365 wtln.r�r" �R• CityS�u�r„-3 Zip 9s`�i Lic# l2 ' Phone# Zff1 ' "6 <br /> C-57 Contractor P �'t1M 4 <br /> Consultant/Sub Cntr lam`-ErN�"flF—a• t^SL Address Z�iSE �^'f RnZJE Cib Sbc ^vLic# Phone#,2��t'fRV`d-t3'f� <br /> y - ,Township I i-�I Range 6E— Section <br /> GIS Coordinates:X 1 <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br /> PEW WELL I BORING_ (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') � 0 OVER-BORE. DIAMETER <br /> 0 SOIL BORING# PRESSURE GROUT <br /> &WELL# nv 3 4 S {3o LJ 40) VL `^'6'u'S GROUT SPECIFICATIONS <br /> 0.Other <br /> COMMENTS: fl) ,(L o E t h 6-V2� t <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS TIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 MONITORING $HOLLOW STEM DIA.OF BOREHOLEJE <br /> a EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS G44.'t0 TYPE OF CASING: 0 STEEL 0 PVC O OTHER: <br /> 0 HOSE <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL71�-, � (-v TREMIE TYPE TO BE USED: $AUGERS <br /> L PUMPED: XYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEA <br /> 0 SOIL BORING O HAND AUGER GROUT SPECIFICATIONS 14 � <br /> 0 OTHER: O OTHER APPROX.BORING DEPTH qr dELO J ("^' pWOLTED TRAFFIC BOX or II STOVEPIPE <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 /> Title/Company 577,-Pf 6+- ►�f�l`1L / �` JL `D� <br /> Signed x <br /> Print Name ^' S^ Date „r � J-� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �D Al- <br /> co <br /> V J _ <br /> WORK PLAN DATED: cow— O <br /> a <br /> Date Issued Area <br /> Application Accepted By Date <br /> Grout Inspection By <br /> Date Final Inspection By <br /> Destruction Inspection By Date <br /> ID 15 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# e <br /> i PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQQUEST# INVOICE <br /> .dnr%l / l/ e 3.31.E SR# Op 1b <br /> C-57 WC_WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br /> _ ,f <br />