Laserfiche WebLink
• \./ SAN JOAQUIN COUNTY `-` FILE COP Y <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 TpppN <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.s' ov. <br /> Uhereade <br /> WELL PERMIT APPLICATION JI', 1 1 2010 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSU VIROiv(l4PUT 14I 111 TH Application is San Joaquin County for a permit to construct and/or install the work described. This appllca�I[@�i IT 1Q th San <br /> Joaquin County Development Title,chapter 91115.3 and the Standards of San Joaquin County Environmental Health DepSrM+eh '`�"�is <br /> r Assesso' <br /> Well Location.11-1.0t Ltfirebcof) Cross Street V7tl �t City �L�Zip Parcel#712 <br /> (� <br /> Property ,L� `r'— �y,� L }� t f..� <br /> Owner t-;LTN 0/ TDCHZQ Addmssnn?,,rrjUUU_ �pj&4+�City '6 b�rr1�f-y,/_Oip Phone# <br /> C-57 Contractor �YQ(�QI ,\��0tddmssCVX W Oy/W e- city(1G I llN 1_`7Lic# X105 PhoneC7� x S'�SLTO <br /> Consultant/Sub Cntr_ [I e4or Address l4(A Lf l/'� itILQ_ City .70 too fin 0.. Lic# Phone <br /> GIS Coordinates:X 31 !6 S ,Y "121•ZSIrJ ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT -POPROB VD,QOPUNCH,HAND-AUGER,OTHER-) [I DESTRUCTION(CHOOSE TYPE BELOW) <br /> [SOIL BORING#_ �1 YJO(rfhC� ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑'OTHER a� 33, �'3 GROUT SPECIFICATIONS <br /> COMMENTS: Sg c>3 � —ao'ir 1 sl�6 — C'I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2-" ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL [I PVC [I OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE Nr, 'r,p061 C1 <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM <br /> pp FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING t❑HAND AUGER/ GROUT SPECIFICATIONS �� r±1 Gln.._!A <br /> ❑OTHER: RI 011 <br /> OTHER: !_ APPROX.BORING DEPTH ~" tZ ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (r YEs,lisl spedfcaiims in romment 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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> Signed C- t'C-IT/ C-i olr)G /� I <br /> Print Name '5N,yV. 141 Dale <br /> 1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: dy7 C <br /> WORK PLAN DATED: �'/ lV�\� <br /> APPLICATION ACCEPTED BY DATE ISSUED `Z6 16 AREA_ja5 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 3s0 <i5lZ03 3 7-t- R <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT —ENCROACHMENT DOC <br /> EHD2901 IVW7(WEB) ■ 'Lf/ fyAPP <br />