Laserfiche WebLink
SAN JOAQUIN COUNTY w <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> o ., VNI 600 East Main Street, Stockton, CA 95202-3029 MITIGATION'' <br /> Telephone:(2091,468-3449 Fax(209)468-3433 Web:',nw_w Ov.qL, -ho, <br /> UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PER1,AIT EXPIRES 1 YEAR FROM DATE ISSUE-1- <br /> Application <br /> SSUE-Application is hereby made to San Joaquin County for a permit to construct andlor install the work descrihec. Tnis appllr_atlan is made in compliance with Sar <br /> Joaquin County Development Tltle,chapter 91-1115.3 and the Standards of San Joaquin County Frniironmentai Health Department <br /> t,.aJq. t n Lo• tC:a al,+ryAssessor's <br /> Well Location `1835 tTn�M"w t`f�• Cross Streets Hr.�,ry e•' L :K� City 5+0 L K itrin Zip Parcel#� t 7 Y90-Z 7 <br /> Property k�o•rley �Tv_:1'y <br /> Owner 'e-aVoee, Ie Address PO (QCT XYD City W:.'i&4 't�F zip 13525a Phone 9(ZO'i3C^7- kj7Z. <br /> C•57 Contractor v h L`' '�"'°i Address �U I 011 9-70 City Lod Zip 95 Z� # 7 7c'Lic9ov Pho illy 9bcro <br /> Consultant'Sub Cntr /* .A 14 S Address !7( ,y �✓•a s Ye e City c S C ^I w Lic k Phcne(lo)E' h- '5� <br /> GIS Coordinates:X 1' Township Range Section <br /> WORK TO BE PERFORMED: <br /> V.NEW WELUBORING(CP?.CEOPRDBE,HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORINGA ❑OVER-BORE DIAMETER _ <br /> ® <br /> WELL /t1.y' '1 ❑PRESSURE GROUT _ <br /> `OTHER _ GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ,�i-HOLLOW STEM? DIS,OF BOREHOLE ❑rAJLTIFLE CASINGS O MULTI-LEVEL WELL CASING DIA 2" <br /> ❑EY.TRACTON ❑AIR HAMMEWURIVEN CASING IHICKNF.SS e>°t^• `I TYPE OF CASING:0 STEEL 12 PVC 0 OTHER <br /> ❑VAPOR [DMUD ROTARY DEPTH OF GROUT SEAL '-L TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OF,CPT)—_GROUT SEAL PUMPED:ElYce ❑'No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL 5OR!NG ❑HAND AUGEP: GROUT SPECiFICA'I IONS 1_�-LlT �C'r"ti�y'j'" tr-•"y +- <br /> ❑OTHER. C!OTHER:_ APPROX.BORING DEPTH 5 U ^BOLTED TRAFFICBOX OR G STOVE PIPE <br /> CriNDUG70R QeSIr.G?a.ONOS!:D VYES,lisi speeifi lien;Ir c�mrasl sac?'x.; <br /> connrtneNTsha�J // ;h�G��r�- �t.itl <• _ _ —___-- _ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REOUIRED FOR INSPECTIONS <br /> 1 hereby certify that t have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Ruies and <br /> Regulations,and all applicable California Laws. / <br /> Signsd Title/Company (1 Y Esu <br /> Print Name °2 r^5 1 7 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLA14 DATED:__-- - <br /> APPLICATION ACCEPTED BY r fY"� DATE ISSUED l u _AREA q q / J <br /> GROUT INSRECTION BY l _,_ FINAL INSPECTION'By DATt Z 7 o <br /> -- <br /> DESTRUCTION!N'SPECTIONI BY LATE <br /> COMMENTS/CONDITIONS! <br /> i <br /> ACCOUNTING ONL AID# FAC 4 <br /> PE CODES FEE INFO AMT REMITTED CHECK k' RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 541 i GIqjlpe SR# <br /> 10K VVAIVEP, C57 LFTTFRi OF AU7HOR!ZATION T^.SIGN PEFrv7•.T ENCROACHMENT DOC <br /> v4ELLPi:RtA11 AYP <br /> EY.D b-0� t1;S.'C7 <br />