Laserfiche WebLink
•i:f <br /> WELL "'rERMIT APPLICATION Fty6M SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 /> / vv,,tt f j Assessors <br /> WELL Location 40,0/'e5ke C t ,zj /;I 1O/ S'f Cross Street`)VJ['!cn/�75 Ae City 51C-61-Cod Zip Parcel# <br /> PROPERTY Owner/_/3V ad— Address �N: �IG(t_�tQd _ City �{C��itLrf)iV Zip 526 Phone# <br /> -57 Contractor M 7 �Or—Vl <br /> Addressl ft-f C I► l.�p_city�= zid 7 2 Lic# j�jVPhon /b &?3onsultant/Sub Cntr r �2 Address &37dq a_s.�7 L(). Ci / Lic# 3 2 Phone — C() <br /> SIS Coordinates:X Y Township Range Section <br /> NORK TO BE PERFORMED: <br /> wNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH;HANG-AUGER,OTHER") DESTRUCTION(choose type below) <br /> Q SOIL BORING# p OVER-BORE <br /> WELL# - Q PRESSURE GROUT <br /> 'Other. r Grout Specifications: <br /> COMMENTS <br /> :YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ]MONITORING iOLLOW STEM DIA.OF BOREHOLE E •Zi MULTIPLE CASINGS?(]MULTI-LEVEL?a WELL CASING DIA:z'% <br /> ]EXTRACTION I]AIR HAMMER/DRIVEN CASING THICKNESS---5---4i40. TYPE OF CASING: []STEEL 06'VC O OTHER: <br /> j VAPOR a MUD ROTARY DEPTH OF GROUT SEAL �/ � TREMIE TYPE TO BE USED: AUGERS .0 HOSE <br /> ]AIR SPARGE/ozone 1]PUSH POINT GROUT SEAL PUMPED: Q Yes firNo (NOTE_ MAXIMUM FREE-FALL DEPTH IS 30') <br /> ]SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> ]OTHER: 11 OTHER APPROX.BORING DEPTH �� )YwOLTED TRAFFIC BOX or n STOVE PIPE <br /> // CONDUCTOR CASING PROPOSED?—.AJC) (if'YES,list specifications here): <br /> COMMENTS: ��(,/��� of GCtS t It rll��c%�� l Ct� i>t) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> �ou Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> 'rint Namel))g n ; i V O.6n In ►&C �X Date 9 (7 <br /> DEPARTMENT USE ONLY <br /> 31TE MAP IN UNIT IV FILE,AD RES : `T 33 <br /> NORK PLAN DATED:L4 S� -1) /7 <br /> 4pplication Accepted By // Date Issued �� ��► J Area <br /> 3rout Inspection By Date �P d3 Final Inspection By '/r - Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> iACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 0f Sn / 6/o 3 355 <br /> C-57 WC_ WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br />