Laserfiche WebLink
�, _� O A�� �- .o .-. ... .«. �. - ,ten y!�* T;-=t „ .•� - - <br /> ,� SAN .ICOUNTY FILE COOAQUINpy <br /> y ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East MainStreet, Stockton, CA 95202-3029 SITE <br /> �. Telephone:(209) 468-3454 Fax:(209) 468=3433 Web:www,sLgov.org/ehd <br /> a¢� UNIT IV <br /> t'MR 12010 WELL''RERMiT APPLICATION <br /> ! ,V'T HL���-�� - NON-REFUNDABLE PERMIT.EXPfRES 1 YEAR FROM DACE ISSUED <br /> rRpPt tl�ASE to San Joaquin County for a permitto construct and/or install the work described.:This application is made in compliance with San <br /> Joaquin County Devel p ent Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Well Location ZZ5J Z t+'�C.W,Y t ' Cross Street k Assessor's" <br /> Pr4pert .6! ,i _. Cilq <br /> Owne ovA` Zip19�1�7 Parcel# CO V-bW ' <br /> � Address ZZ .w�ufx�4- _0 POW �u <br /> City Zip Z[?2 Phone <br /> C•57 ContractorAk 041 UkW&kdress" liaA i`Ge Cit ` luoruF to A <br /> p j�J Lic#q� Phone <br /> ConsultantlS}� ir. Vb111MNAac�A� Address�0�tiu(n�l�it�r �? Cityt1 PM*_d dI� Lic i 5$0 Phone s <br /> tal$Coordinates:X - ,Y <br /> Range QSection t <br /> WORK TO BE PERFORMED: j <br /> x,. <br /> ❑ NEW'WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTfON(CHDOSE TYLOW) <br /> II l]SOIL BORING# is OVER-BORPE BEE DIAMETER -tF� <br /> ❑WELL# ^I �RESSURE GROUT W- <br /> ❑'OTHER ROUTSPECIFICATIONS <br /> F p EXPLOSIVES DETONATING CARD 3 <br /> COMMENTS: Wu1 tLQ!.NGRRaCy IuC. 'I IY BGG 7 i >f GtV10u C t{�1�1Y \�' <br /> TYPE OF WELL INSTALLATION„TYPE 7':C6f1ST14 CTION SPECIFICATIONS 3 v, <br /> Y&ONITORING ;111iOLLOW STEM DIA OF BOREHOLE ” ❑MULTIPLE CASINGS❑MULTI-LE=VEL WELL CASING DIA: �K <br /> c. / <br /> (3 EXTRACTION ©AIR FIAMMER/DRIVEN CASING THICKNESS 7vi� 0 TYPE OF CASING:❑STEEL P VC ❑ OTHER <br /> ❑VAPOR u ❑MUD ROTARY -DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSI <br /> 0 AIR SPARGEIOZONE ❑PUSH POINT(GP OR CPT)"Fi,GROPT SEAL PUMPED:❑Yes ❑No,(NOTE: MAXIMUM FREE-FALL DEPTH IS 30*) <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS ' <br /> ❑OTHER: ❑OTHER: APPROX"BORING DEPTH — ©BOLTED TRAFFIC BOX OR 1]STOVE PIPE x <br /> 4 .C0NdUCI-dR CASING PROPUSEP -,_ __ R YES,list specifications in comment sactionl <br /> COMMENTS: . <br /> NOTE: OFFSITE BORINGS REQUIREACCESS AGREEMENT OR ENCROACHMENT-.PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS 1 <br /> hereby celaalt <br /> I have prepared this application and that"the wot0will be done I-accordance with San Joaquin County Ordinances,Rules-and � <br /> Regulationapplica le California Laws.. 4 _ w .* <br /> Signed Title/Com an 1 Gtto�O Cyd �O�ti <br /> p v_ �rtYoKvue�'�xI 1 <br /> Print Name pate Z 74 t <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS~: '.g K' <br /> t: . <br /> WORK PI.-AN DATED: <br /> i r <br /> APPLICATION ACCEPTED BY ` . •D TE t �� �[0 ; AREA <br /> GROUT INSPECTION BY FINAL INSPECTION l3EarED .�"�L� <br /> DATE <br /> DESTRUCTION INSPECTION BY, DATE 3-tS^(D <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FRC#' t " <br /> PE CODES FEE INFO AMT REMITTED CK# . RECV'D 13Y DATE AERMITISERVICE 6fNVO[CE: <br /> - - -- <br /> C-5 WC -WAIVER --- �� C57 ETi OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DO <br /> EHD 29-01 ,10128/09 }..__ , . .. . w- „�.. -WELL PERMIT APP <br /> I <br />