Laserfiche WebLink
4'-dui San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> .! <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjcov.org ehd OMIT 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 /> / ( r //G1i' -�� py_IZ �, Assessors _�3 <br /> WELL Location/ter 11 r� !t'v ° C I vii Cross Street 1T City Zi Parcel#OS,r—Q TO— <br /> PROPERTY <br /> Owner i �? Civ r 5 G Address!QjZ 1 tom'Fq ja*City>�G k"LV3 Zipt1S 2.l Phone# ?_o, ` 7 <br /> c)j b7S- i 02- Zc� <br /> C-57 Contractor i�1 C?i I t" �( � Address 21--1 01'r-fit <br /> i{'_ Sfcity"- 'hc�0 k" ip Lic# Phone#2—"-'t—61 <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other O'er n _, F n r t GROUT SPECIFICATIONS NF-'iiN20v✓� <br /> COMMENTS: — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Af <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE !j '0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL �VC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL a TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER i GROUT SPECIFICATIONS_Ala/e!i �B G1i 0. ✓f <br /> `PJ OTHE�) OTHER SJ It f� t'rnAPPROX.BORING DEPTH N—� 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> /C t'� �^I � %Pt 1✓(��E� �li� CONDUCTOR CASING PPROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: Ir rJ V nl I�-P i I'm It g r T sF I Sini e� <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 �pre ared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rule and' ReguiabWs, and all applicable California State Laws. t <br /> Signedx `� �`'��— Title/Company <br /> Print Name ��t !� G(`(A CID ejalt -S A Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED:A <br /> Application Accepted By ti� Date Issued $ �'-/ Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> ZR SR# <br /> C-57 ✓WC V WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />