Laserfiche WebLink
i <br /> �nn SAN JOAQUIN COUNTY <br /> (�UENEOHNVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> 1; 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> �I IJL 2 J hone:(209)468-3449 Fax:(209)468-3433 Web:www.siaov.org/ehd UNIT IV <br /> �`at <br /> OR <br /> ENVIROWr1ENT ;1FALTN WELL PERMIT APPLICATION FILL <br /> PER►s,^i(/Q'R�IIrF�6-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 worts described. This <br /> Joaquin County Development Title, &11 5-3 grid the Standards of San Jo application Depart is made in compliance with San <br /> chapter v aq '/Co,��v Environmental Health Department <br /> Z u +I GN r U i 7- //� Assessor's <br /> Well Location C0�3 I Cross Street c- ✓-) G .« City S/a! /�-'f u.,Zip 1 0 /,parcel 31- C 2(0- 2 C <br /> Property (- <br /> Owner E ri-1 L�V'sAddress _ �I7y c✓� p = <br /> Phone 7 - C�1 <br /> C-37 Contractor y Address S city, 4 Lfc-,14�Wrione 1_` S I _ c z� <br /> Consultant(Sub Cntr Address City — Lic# - Phone <br /> GIS Coordinates:X Y Township - Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW <br /> LIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) [IDESTRUCTION(CHOOSE TYPE BELOW) <br /> WSOIL BORING# 13- 1 13- 2 - 3 ElOVER-BOREDIAMETER <br /> 0 WELL ❑PRESSURE GROUT <br /> ❑'OTHER r GROUT SPECIFICATIONS <br /> COMMENTS: <br /> ! TYPE OF WELL INSTALLATION TYPETION SPECIFICATIONS <br /> ATKNNS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE L- ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> [I EXTRACTION ❑AIR HAMMER/DRIVEN CASING 7HICFQJESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR y❑/MUO ROTARY DEPTH OF GROUT SEA-_LJ11L TREMIE TYPE TO BE USED❑AUGEt1l SE <br /> ❑AIR SPARGEIOZONE Ip PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:} Yes No (NOTE:MAXIMUM FREE-FALL,DEP � <br /> SOIL BORING (\HAND AUGER GROUT SPECIFICATIONS 1� G I .L (� <br /> _T / , <br /> ❑OTHER ❑OTHER: APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX TOVE PIPE 3COMMENTS: CONDUCTOR CASING PROPOSED (s YES.�y in wm <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 la application5d that the work will be done f accordance with San <br /> Regulations,and all b rnt ( Joaquin County Ordinances,Rules and <br /> Signed p Title/COmpany �" I "' - 1'W V1il l{{�Q �v►I f ''_I 'Vtlf I <br /> Print Name C' 1� -1 Date <br /> 1 i <br /> i <br /> DEPARTMENT USE ONLY ZQ s O I <br /> SITE MAP IN UNIT IV FILE,ADDRESS: o Clef' <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED 7-27-o9 AREA <br /> GROUT INSPECTION BY RNAL 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 /> X20 �� ll03 2- �•Z -off i <br /> C-57 1hlC V 77AIVERiL <br /> C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC IM <br /> EHD 29-01 1107(WEB) WELL PERMIT APP <br />