Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> z i SITS <br /> n { E i*ONMENTAL HEALTH DEPARTMer MITIGATION <br /> 304 East Weber Avenue, 3rd Floor, Stockton, �MCA 95261-270 UNIT IV <br /> (209)468-3449 •Fax:(209)468-3433• Web:www.co.san joaquin.ca �(�JT <br /> WELL PERMIT APPLICATION FORM APR 19 2005 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS3lAWOAOUIN. <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. ThisF�kyl i compliance with San <br /> Joaquin County Dev�e�llopmenttTTitle,Chapter 9-1115.3 and the Standards of San Joaquin County Environ/me/n�tafV P �} ? <br /> essors <br /> WELLLocation -/ �O / �' �arlAn A'CrossStreet City -I'/TYtFI L &4a ' Zip Parcel# /"IJ-200 <br /> PROPERTYOwner 1GYo Address Z2 �'mrk AUQc Al o17Z 212 2045 <br /> 1 � LIty Zip I ,�,Pahone# p-�30r <br /> C-57 Conte B8 a '�. ' t r- - tOOj Ar�dd(r`ess )06K-0466 Clty tP p Juc# -19'5 &one#g -7 W <br /> Consultant/Sub CnV 1-I.Uk-t d- iZ i.t't"'T P,ddress ��� �• �a�„r�+d'A SGl (DJe_ (�C# Phone# �D g�'1S J�y-Q <br /> GIS Coordinates:X ,Y ,Township �� Range�Section 2 <br /> W RK TO BE PERFORMED: <br /> NEW W ELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION(choose type below) <br /> a SOIL BORING# D OVER-BORE-DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> O'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR . 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> n AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: H OTHER APPROX.BORING DEPTH p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 OrdinAS'RUles and Regulations, and all applicable California State Laws. <br /> Sig Title/Company to <br /> Print Name i 0/• Date 1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: //1 /^ rJ n <br /> Application Accepted By (- ,' V Date Issued ao,i ( ' tQ <br /> v m-,) Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By ' <br /> e <br /> COMMENTS I CONDITIONS: <br /> a <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DAT PERMIT/SERVICE REQUEST# INVOICE <br /> ZiD 09 1 22152, Ob sR# loql q(o-7 <br /> C-57_ WC--WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 WELL PERMIT SITE <br /> sm/2003 <br />