Laserfiche WebLink
WELLPERMIT APPLICATION FtifRM SITE <br /> r 1-% SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 _ <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.Assessors <br /> Joe- Pa.ftho9 s3-7b Parcel# <br /> WELL Location�3fa0 �'fin+ L,(�Q Rd Cross Street kw CityTrTtC� Zip <br /> PROPERTY Owner -L=12 V2 A „C C. Address P0, QO 711 City Iia l lgS '1-X zip'-7.T223 -Phone# <br /> C-57 Contractor�re {•'S� V Address 9S0 4tAAfP— City tor-+'jAe2Zipa� is#t,c�4o7Phone# <br /> Qanc h <br /> Consultant/Sub CntrSc�CCe pQr1�0. lora Address1CiT>� City CgLdcvc7 Lic#b5`� 12S Phone# �16� b 1�0�/QC� <br /> GIS Coordinates:X ,Y ,Township_ Sb LtV, Range S C a 5' Section <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br /> ANEW WELL 1 BORING JCPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER") 0 OVER-BORE. DIAMETER <br /> `CSOIL BORING# �{��'-, n PRESSURE GROUT <br /> n WELL# GROUT SPECIFICATIONS <br /> n'Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING n HOLLOW STEM DIA.OF BOREHOLES n MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> n EXTRACTION D AIR HAMMERIDRIVEN CASING THICKNESS T TYPE OF CASING: D STEEL n PVC D OTHER: <br /> []VAPOR n MUD ROTARY DEPTH OF GROUT SEAL D TREMIE TYPE TO BE USED: n AUGERS WHOSE <br /> n AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ")rYes n No (NOTE: MAXIM UM FREE-FALL DEPTH IS 30') <br /> SOIL BORING n HAND AUGER GROUT SPECIFICATIONS <br /> � BOLTED TRAFFIC BOX or []STOVEPIPE <br /> n OTHER: n OTHER APPROX.BORING DEPTH �� D <br /> CONDUCTOR CASING PROPOSED IVy^(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 Joaq� <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> f 1-pp��' TitlelCompany o' u' 6-e <br /> Signed x i SI - S CO� <br /> 1�r`'an C�rP� Date <br /> Print Name 7 b <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: C <br /> WORK PLAN DATED: t I L <br /> Application Accepted B <br /> Date issued -:7- oY Area Z! <br /> y L <br /> .a. D Final Inspection By Date 2 4 <br /> Grout Inspection DDate <br /> Destruction Inspection By Date <br /> COMMENTS I CONDfTIONS: <br /> 7ACC-;0UNTING ONLY: AID# FAC# <br /> FEE INFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMITI SERVICE REQUEST# INVOICE <br /> *e(.00 S 13zz-j ti{ 07 SR# O I I <br /> it 9/30/02 <br /> C-57— WC=WAIVER C-57 Letter.of Authorization to sign permEncroachment doc <br />