Laserfiche WebLink
WN <br /> �/](� SAN JOAQUIN COUNTY <br /> V LSU� ENVIRONMENTAL HEALTH DEPARTMENTSITE <br /> 600 East Main Street, Stockton, CA 95202-3029 2CO�/e hone: MITIGATION <br /> p (209)468-3449 Fax:(209)468-3433 Web:www sigov ora/ehd UNIT IV <br /> ENVIRONMENT HEALTH WELL PERMIT APPLICATION <br /> PERMIT/SERVICES 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 /> Well Location y7/�1� a Cross Street Gj gA vfc !a0C4.,, qS _,., Assessors <br /> Prope /• City Zip Parcel# 1397-4011 <br /> './Owner .4,1 6W ffL%4 &^n*% Address UN LwAlt n. G1w,'.o pn City��� ZIP 3 Phone# S.$ G <br /> r'lrhJttbedl 1 Co. Iy 3.Z,N I <br /> C-57 Contractor(/gSC�hr�OE VLKUtvL INIC,Address A 3t flwtet C4 o City JA Lic#717$10 Phonetpl -b38. It 69 <br /> Consultant/Sub Cntr`7(.(,/}� gddress�Et City, hALic# Phone &- �. 2O7Q <br /> GIS Coordinates:X ,Y Township Range 9 Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# Off OVER-BORE DIAMETER (e ' <br /> ❑WELL# [I PRESSURE GROUT <br /> [I'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: )did. kwe-b tyal stroll LL ..... ., - ZD Lpt rOCP A 'IWC to.t VKIt>r O <br /> Ahme r,tLn_ xl Ows t neAT60^Aw r APea- TOIK <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE L' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC [ OTHER <br /> It VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL N 0' TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes M r N0 (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: OTHER: APPROX.BORING DEPTH TIO ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> 1� CONDUCTOR CASING PROPOSED (f 1rPS,!gl sPeafi na in mmmen[section <br /> COMMENTS: CDA(NSC e�w,Z RA (1��1 VpDW paa— �� A{ S, `i l C� Su a <br /> m� <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 p e ared this a tion and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations a}nd�ail a lic�,,4Lle\S IIiffomi Laws. \ ) <br /> Signed .gyp \ �)r> ` ' >L Title/Company EWV. �Er, CA re-t (' jl+n1 <br /> Print Name . �. 1r.L�,A„-lam Date 1. to• <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 43 -2 <br /> WORK PLAN DATED:_ III 20 167 <br /> APPLICATION ACCEPTED BY 'Y►'�. '�-/� �^,�� DATE ISSUED 1_I � AREA 9�y <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: -5th S ,7 L -I pyo <br /> SG I- 5' 5Gg Iq 0/ <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO TTEDA�CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 350 — !0 0 $310 SR# (0303 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5M7(WEB) <br /> WELL PERMITAPP <br />