Laserfiche WebLink
V �KiC vl�A�tvl�l'i �da�IlV F4/` �� <br /> ENVIRONMENTAL HEALTf DEPARTMENT - <br /> SITE <br /> 603 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> . ' Telephone: (209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <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. <br /> i_ ,, tt��y� AssessorslQ�_ZOO--7q <br /> Well Location �_ �,u.. > -1a�. Imo^ 'd. Cross Street '~ �' �"'� City `''`'�r°C Zip Parcel# <br /> Property,, j .j if:^ ',;, n `:.1..�,-^c I) ',.,s; <br /> Owner -•)"-!.✓,nc:;,2.,� .-;"� Address '• ' iUti ter;_ City Zip Phone# <br /> C-57 Contractor cv Addressit\u city '�`L""%"t'` Lic# ' Phone <br /> Consultant/Sub Cntr ° '^-^ov.,., ddress j13 .ltm C,^,_., ,.G, §51'- City "'•�.�+.„ `'"li Lic# Phone.'>`'e-7l: - <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK.TO BE PERFORMED: <br /> ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER') []DESTRUCTION(CHOOSE TYPE BELO`AA <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑ PRESSURE GROUT <br /> [q*OTHER T-'ot.P - '+ kg� GROUT SPECIFICATIONS <br /> COMMENTS: J_I + v <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE I -✓t. ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑ EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER. <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> El AIR SPARGE/OZONE gPUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH1 `�� ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulatios,and'-II pplicable California Laws. <br /> //// qI <br /> r I (' , T <br /> Signed (l' siv'� Title/Company C,fI Ce G'•'6 fCk ' + J�!'y ;,,} Ct^ dr.n V +� (i F•n+ <br /> Print Name A I6I-• GJ:n Date <br /> / <br /> DEPARTMENT USE ONLY <br /> J - <br /> SITE MAP IN UNIT IV FILE,ADDRESS: l S 6 D s P? /L !'^� <br /> WORK PLAN DATED: o� 69 <br /> �q G/ <br /> APPLICATION ACCEPTED BY .- DATE ISSUED O a AREA <br /> GROUT INSPECTION BYVtar n A o­ <br /> FINAL INSPECTION BY DATE �� <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 PERMITISERVICE# INVOICE <br /> 50 L40q s y®� %vv� 7/36/0e) sR# X1`1? <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT e�- —ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />