Laserfiche WebLink
raf � SAN JOAQUIN COUNTY � <br /> ,V =4': <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Tele ( ) ( ) MITIGATION <br /> - � g phone: 209 468-3449 Fax: 209 468-3433 Web:www.sidov.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 fora 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 /> lrJ � Assessor's <br /> Well Location4 D,5 + t57 S,� T h� � � Parcel <br /> # 229 (L1 3 <br /> Property `7 ' c�- <br /> Owner 1`.1, L'u Gr�kt Address 1pt�2 (1L City el(2c)'•j Zip Phone# <br /> C-57 Contractor (.�C� %1 f UNh Address &-"W Cit 9zJ <br /> %��' C/���� JJJJ y �:.i ttJ�-� Lic# ���r�Phone <br /> Consultant/Sub Cntr oC i c 170,-Aidress 127`5 01( City 'Y' Lic# P6one <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 BELOW) <br /> E3 SOIL BORING# OVER-BORE DIAMETER R t' (a►I*''9 <br /> ❑WELL# RESSURE GROUT <br /> [3*OTHER GROUT SPECIFICATIONS /VE/+'I- f� <br /> --oV-►r'brn H-1M�w' °� <br /> COMMENTSr�r,0�,,�, ow� MW-I TLf-!!Sk tr<w-to,,JWw-tilk I- r -1 Dro�.�a &u�ty� 3 el�ttD ��LLwyw�7`7l <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> c� x 1 u <br /> i?MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE p_10" ❑MULTIPLE CASINGS❑MULTI-LEVEEL( WELL CASING DIA:Z" <br /> ❑EXTRACTION [It7l.AIR HAMMEWDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL PVC ❑ OTHER T <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS '4) - <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH l TO BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASINO PROPOSED (f 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 Ce$ that ave prepare th application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations`, ! ippticab Cali is LawS. <br /> Signed � Title/Company 142 j)& n <br /> Print Name Date --1�2 -�—J <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: l <br /> WORK PIAN DATED: <br /> APPLICATION ACCEPTED BY �-` DATE SSUE AREA f <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE �( "�'^t. <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 /> Lo 3-6 3C �C,� S11#514AI <br /> ;, . <br /> f_F7 1AM' _1111A 1\/CA (-r,7 I C: T9:P(11=W ITWr)P17AT1nh1 T(1 CI(_N DCGf. AIT <br /> CRI(`D(lAf`I-7�Al=AIT rl(lf <br />