Laserfiche WebLink
oPq�l."'•.c AN JOAQUIN COUNTY <br /> 1J ! IT 1 ttast <br /> SITE <br /> TMENTAL HEALTH DEPARTMENT Main Street, Stockton, CA 95202-3029 SITE <br /> . •.. Li itJ Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.s*gov.org/ehd UNIT IV <br /> q�l FORS` <br /> EN IR0+NMiFN T HEALTH WELL PERMIT APPLICATION <br /> PER N,ff//`)ERVIChS 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. <br /> Assessor's <br /> Well Location Cross Street 0t-j,O,q S-h-ee'jCity Sfi cl,'oN Zip 95205 Parcel# In 02-)0 1 <br /> Property r1 / <br /> Owner iws��/�tiolte� iit,a Iwf�Address �•d• S� City ho�.*I" IR-'CL' Zip 95 'Q Phone# '754-01'-s <br /> C-57 Contractor Address 2365 •D, City -S�arkC b^ Zip9640!5 Lie# 6-S"�4 Phone <br /> Consultant/SubCntr ATCAssaugf�5' Address lllj•L,,-,e P,1,,ve, S ,4e 2-0 City I'ijes4v Lie# Phone 2()5-579-2221 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# ❑OVER-BORE DIAMETER <br /> WELL# 05-1,W-Z,05-3,66 ,05-S El PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> ElEXPLOSIVES DETONATING CARD <br /> COMMENTS: 1 w¢II 4„ levee. r 'z ""e(li 4p Sevea— ,Z veif jl/ u-t e t°le)[7 : ; ]Xvee" .4 SO SS- c -;o-3s" t <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS l t <br /> ❑MONITORING HOLLOW STEM DIA.OF BOREHOLE go` 04 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:2 <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS SGt^ gV TYPE OF CASING:❑STEEL XPVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL V--Ce) TREMIE TYPE TO BE USED K AUGERS❑HOSE <br /> 'KAIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:0 Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 1!3 1,14 Io `�S BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS +�. <br /> pi. d <br /> I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,11%vnd <br /> Regulations,and a is California Laws. <br /> Signed Title/Company 5+A) Crotc� � a <br /> Print Name el=:� Date M.X ICle 2-010 <br /> 7- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: wck,. <br /> IP m <br /> WORK PLAN DATED: <br /> Z $ ✓'f� . . <br /> APPLICATION ACCEPTED BY DATE ISSUED S f O AREA <br /> GROUT INSPECTION BY A)�ft 4ti,t vn 6 I(0 FINAL INSPECTION BY DATE Z 10 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 3Sd3 f y3y, 00 2-65 SR# 50/ <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT �_ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />