Laserfiche WebLink
*San Joaquin County <br />Environmental Health Department <br />600 East Main Street, Stockton, CA 95202-3029 <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />RE <br />JUN 2 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HFALTH DEPARTMENT <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/eha <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 />Assessors <br />�C Z <br />WELL Location 1 I '(.+ ��1 Cross Street 1 /t t City zip 61526 <br />PROPE TY >'10''' L4-Zf30(p ("V <br />v <br />'o,�. I 1 x I ��� �y, `Gt1IC/i <br />Owner (00 ��1," `✓, Address c3�'(1 1y V N, City �'LtL V1 Zip_�52419 hone# <br />V'/ �� �,,>� (1IUAt/11°rt'�Z��ii'�?�. <br />1O W01 � Address SD Cit <br />C-57 Contractor y�_Zip ic# Phone# 7i 3 S <br />Consultant/ Sub CntrW�r &0Lk:S Address a\VZ I-kO ,ASt , S'( 200 City ?01-'A Lic# 3t lQ Phone#% (f <br />GIS Coordinates: X "\'10 I <br />\/ -OI %.A? I y0:i(o'Y -�S `01'g)'d , Township ( M Range � � Section <br />WORK TO BE PERFORMED: <br />D NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) ADESTRUCTION (choose type <br />D SOIL BORING # OVER -BORE. DIAMETER <br />D WELL # D PRESSURE GROUT <br />D *Other II GROUT SPECIFICATIONS <br />COMMENTS: '�� tM� t UCS - C) --- <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 1% <br />ONITORING 0 HOLLOW STEM DIA. OF BOREHOLE D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS /V1 Lj 0 TYPE OF CASING: 0 STEEL J.PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE <br />D AIR SPARGE/ OZONE D PUSH POINT (GP or CPT)GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS —ty-��rYu�— 62 <br />0 OTHER: D OTHER APPROX. BORING DEPTH 31 n BOLTED TRAFFIC BOX or D STOVE PIPE <br />CASI <br />(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 I have prepared this application and that the work will be done in accordance with San Joaquin <br />County OrdinanceMsd Regulations, and all applicable California State Laws. <br />Signed Title/Company VA's e'I' <br />Print Name -Ci' (,' b Vq Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By wy(a �i c C7�« �`'' �6 0 Date Issued 6 '� 0� Area <br />Grout Inspection By / 1� Date Final Inspection By '-e ate -7Z"O <br />Destruction Inspection By Date 74 f ©,& <br />COMMENTS/ CONDITIONS: 6fV144 d aa4e*­t i lYt-0- K . Y-2- 6 XP_ eae-c Cle jj <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />W 79 <br />kO I Lo — <br />`F 2-3 `f <br />SR# <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />EHD 29-02-001 WEB <br />9/11/2007 <br />