Laserfiche WebLink
oPY vFG WELL PERMIT APPLICATION FORM SITE <br /> SEG SAN JOAQUIN COUNTY MITIGATION <br /> 200 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 31 304 E. Weber, Third Floor, Stockton CA., 95202 UNIT IV <br /> MPR AohQ P (209) 468-3449 <br /> EN �tpEPP NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applica�ty�pl Areby 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 /> Joaquirt County Development Title, Chapter 9-1:15.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ////'' /7 't ) Assessors <br /> WELL-Location �5 -50 S, /rZ'00" 2d- Cross Street J Si= City La�EI`rOI° Zip ..s 33C Parcel- <br /> c'/4 S1epk�r✓I Vh�ccbr`fo /(/c �✓ldF <br /> PROPERTYy ((�� QQ �/ <br /> Owner 71ZY'cc.�i.2_ ] rte+ Addrer.spf� 6 LK,� jj.. <br /> r� i O City LIi'Gl.(L zipT`/S�� Phone#('�/y2j�Q3 -G3'(�O n// <br /> C-57 Contractor/Sr2�rL �N- )(k/ Address C) a? ✓.00r-� Cityrla-✓"�LL'tQL 5-9 <br /> --I//�t�( _�-�,/ -� 333G 65ate^ -of- ry -t� Phone. /LS�3/� OC) <br /> Consultant/Sub Cntr7 1--&- V 7 &,y _Address ,fig !f (7Z-n City CFI,, r Licl(Ui J%7 T Ph.ne#(O 3Z�G-1-9 6 0 <br /> GIS Coordinates.X ,Y__ Township /S Range 6 Section z-F <br /> WORK TO BE PERFORMED: <br /> � 'NEW WELL/BORING /cPr.G PROBE. HYDROPUNCH.HAND-AUGER OTHER*) p DESTRUCTION (cnonse'yp=below) <br /> BORING# 0 ")•- Y� OVER-BORE. DIAMETER <br /> (]WELL# p PRESSURE GROUT <br /> H"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING H HOLLOW STEM DIA.OF BOREHOLE�t_ []MULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA <br /> [[EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING []STEEL 0 PVC, []OTHER`_ <br /> []VAPOR (1 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE `[.(PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING o HAND AUGER GROUT SPECIFICATIONS <br /> []OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or p 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordd/(jt antes, Rules as Regulations, and all applicable Californian State Laws. ( S <br /> Signetlx�f J ✓LGG✓ ' t�,G/vTL�L +"1�� TNWCompany / L�f� Al�/" fyYiJY C.✓t V�rrrl lvlz.-;� <br /> Print Name <br /> 1�pto-4k l.�A.-/ 'K-4 h�-[ Date j 2-cl e� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: I S(e Q Q <br /> WORK PLAN DATED: <br /> Application Accepted By /r l Date Issued �/�i" Area <br /> Grout Inspection By im pate 0 Final Inspection ey"y1'tTT" Dat <br /> Destruction Inspection By Lj Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK* EREC'DIBYDATZEPERMIT/SERVICE REQUEST# INVOICE <br /> sR# 37-771_ <br /> C-57_ WC=WAIVER-_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />