Laserfiche WebLink
WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY ,o �,��� <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) ��' IA;FY <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209) 468-3449 - <br /> AR <br /> (209) <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTHI <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is ma&Fe%&ri�Ea' (van <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location 42o w. -ilp ave, 23'J_ _1 . ` Assessors <br /> Cross Street Vert 1 t1S City t,C�000 i Zip Parcel# <br /> me—I,V42!- TZ�.r�'2ra- <br /> PROPERTYOwner Area- Sz-Jtvs Address 2-520 Oakev+,ljie.lc) City -D�vtS Zip 5 1I, Phone# <br /> C-57 Contractorlet M Address 950 BOUJO, City ulAv.: vAe? Zip�3Lic# ` i65Phone# y25-313—`��ov <br /> Consultant/Sub Cntr G�wt� ►a Address 2-7c P���+hS City Sbhnn,a-Lic# Phone# -10'1 -935--4bS40 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) t DESTRUCTION (choose type el w) <br /> 0 SOIL BORING# VER-BORE. DIAMETER I�e/p <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> L2'MONITORING 3� 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> �,WGAPOR C�) 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 1 CONDUCTOR CASING R POSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE AC ESS 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x- Title/Companypy,6�ec,# Geolog'i-, -, Cat>w + vlrt'nvva2t� � <br /> Print Name AtA6re C-3Ok Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By �-din-�' ` Date Issued 7/k � 3 Area 9 7 �P L <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date S /' D <br /> r— <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 5-0'�— (o ('-�n So-2- �le- yI a 3 SR# 00 3 3 t!,o <br /> C-57 WC -WAIVER C-57 Letter of Authorization to Sign permit Encroachment doc 9/30/02 <br />