Laserfiche WebLink
Not V! SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT REr <br /> N. 600 East Main Street, Stockton, CA 95202-3029 DEC I�IIbTj@j#TION <br /> -... P Telephone:(209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.org/ehd UNIT IV <br /> FORCE <br /> WELL PERMIT APPLICATION ENVIRONMENTAL HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 Developrrrr��eelit Title,chapter-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> C"r-1 fS%" mi� �' S,L1nc.^ Assessor's <br /> Well Location W S F- ti33 W. Sr--44SCross Street SC.a�4S AVS, . S-N£L+ City ST9C-Kr,-.^ Zip CiSZO'1V Parcel# <br /> Property <16 IDXrl 1 AVC- <br /> Owner CIT-1 <>F-5 XTnn/ Address 195' N• I&1 Pompy, S�. City -S itc-KT�n ZipgSZ4Z Phone#ZoR —X13 7-10,15 <br /> C-57Contractor ASI Address 2.Zo A/- EAS} S-'1`. City WoojIlA•✓O Zip s9 T76 Lic# $ibZ334 Phone <br /> Consultant/Sub Cntr .G . Address 9;7 by•S l4A W -S4 • City S1-9 C IC70^ Lic Phone 26T -9t 7 J <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(CHOOSE TYPE BELOW) <br /> ElSOIL BORING# <br /> ❑WELL# T /LL37w� <br /> F1'OTHER GROUT SPECIFICATIONS <br /> G�2.orti7- <br /> COMMENTS: NDOn pF�-S/•1>; 1N�) /� S <br /> W P1- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that 1 have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. �1 1 ^ <br /> Signed /��rwy•� Jf l?.,t Title/Company Ani ftT MAnVA(rI� / X76` c <br /> Print Name /f ivin 7 I��, J. v FI Jig r Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3 CO S <br /> FIL E Poop <br /> WORK PLAN DATED: Aj A <br /> APPLICATION ACCEPTED BY DATE ISSUED Z- / /0 AREA <br /> GROUT INSPECTION BY _ �� ,� �� FINAL INSPECTION BY DATE L �� <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 PERMIT/SERVICE# INVOICE <br /> 3 5-0 2 <br /> 35-03 1 3".00 2-0b5 I2 1VII.0 sR# 61bsIT <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />