Laserfiche WebLink
Boa.. �Q `man Joaquin County <br /> aU t+v <br /> Environmental Health Department SITE <br /> �i 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.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 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 /> �1.,. <br /> I�� , <br /> WELL Location Db�31bC rlt' Di-�� 1111 c y/n S7ross Street W�G�O!�S�i/PCity � _Zip q Assessors <br /> 03 Parcel# N'& <br /> PROPERTY <br /> Owner�'1}tiD S,6e_&tCN Address 345,✓, Fl(�G✓defy Sf City.' 6lc6 Zip d2 Phone�937^ 49 <br /> C-57 Contractor s j ( Address �7 SV[Ct�v ILG� City[L& Zip fS Lic#4 D07Z.?1Phone#46 7-/0 V6 <br /> Consultant/Sub Cntr/�}0�1/Qti(,tGl�ICIJ �_^U Address 8.1 7.5hctn.J IW City5j Lic#6292Z_7Phone#'467-1 doe, <br /> GIS Coordinates:X _'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> ROIL BORING# ] 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_2,f 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:A�L,�' <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL, h}-i►�Q TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes ,B'No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> NISOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS _Z701'��G�!Y Pi( 'Le—r <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH �?C�_ 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSEDA)IIA- -(if 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 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�1 / �� \ <br /> `,— - - Title/Company -"4-I <br /> t� <br /> Print Name okV�\ ` �(l�\ Yy -\ Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADPRESS: 3 SC-0 . <br /> WORK PLAN DATED: Y 0 S <br /> ,,�c 1 o <br /> Application Accepted By C/r Date Issued 7 � � J Areaq <br /> Grout Inspection Byk'---AAAADate ZS d Final Inspection By ►� Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3� �3 ?/d416-5 <br /> SR# 13 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />