Laserfiche WebLink
o D SAN JOAQUIN COUNTY <br /> H ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> �! Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.siaov.org/ehd UNIT IV <br /> EOre%' <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 /> Assessor's I <br /> Well Location IOL 5. v•15eVN 1,J,4 CrossStreet Mo'ke.� S�Ye-�'� City $+0 fj_j1 Zip _2 or <br /> Parcel# 1556204.37 <br /> Property 1 <br /> Owner TA S w'y AkH{-ca� 1 Address V714 4. Malk2 -f' Sf, City S�'Tt L I r^� Zip 9372 o S Phone# <br /> C-57 Contractor TE Lr Address 113376 Moriel F.,rl. Place City R-. clp Cwdeva Lic# 76b Sb9Phone ILilb)B53-d'd Io <br /> Consultant/Sub Cntrlrnv.A -cc,. .4,41 VZAddress llly Sf- city E.4a.1lw Lic# Phone h-eg)U38'-�/Ptrb- <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# S U-1115S W 2 4137 1 4 ti 4 S V S S V b ElOVER-BOREDIAMETER <br /> WELL# r t ❑PRESSURE GROUT <br /> ❑`OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE T/4" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:AA <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS NR TYPE OF CASING:0 STEEL 0 PVC 0 OTHER <br /> 0 VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL S TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br /> ❑AIR SPARGE/OZONE FPPUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:0 Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING 1❑HAND AUGER GROUT SPECIFICATIONS NP..-F c2�*- G,e,lr <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH S 1 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (e YES,list jedfi a1.1 ns in comment section) <br /> COMMENTS:4,;A tr n1+W4 Ava^<ed {o Sr yr oft eP tal(P•><-«n Sa•wyPv✓ Su..,.0(QS• <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby certify that I 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. <br /> Signed J`t— 6CA Title/Company $46`FF IJ'Gs eo� ice/ Irro ✓ICI Z«o <br /> Print Name v ryc 5o/N Z Date 3 /a at <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I OZ S, (�I(SpN J / :5+,x C Yon e -A 9 5265 <br /> WORK PLAN DATED: 'f'9 �S/�Irs ( Q 0//9 <br /> APPLICATION ACCEPTED BY /!/v(� 1�✓e!°,�s? DATE ISSUED AREA /V 379 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COM MENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# I INVOICE <br /> ?s003 - Y pO 019-763 9 Ry Pf SR#005846y <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EMD 2901 11/Ste7(WEB) WELL PERMIT APP <br />