Laserfiche WebLink
� Q '" • SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> i <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 Develo ment Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> /Vdier/7� S/,DE ele-7^4.2-�ldG./ 1` , Assessor's p� <br /> Well Location «i✓��/GL Cross Street I-Cc, P'�e City � y Zip/9 S37T Parcel# �r3— b3 p <br /> Property <br /> Owner,5�✓C"PNA/ t�/� �/�� ress /�/O E/f/rLl4 G%fJ� ity S'%G2'C%�D✓Zip 9�1`�Phone#C•?d� ¢Oo'3 X66 <br /> C-57 Contractor el_ `���P� Address �/�O ,�P/�u ��� y/JN;1(cjaf Lic#71 yloP oone 70 6 <br /> Consultant/Sub Cntr Address City ,� Lic# Phone <br /> GIS Coordinates:X Y Township ��"`/"� Range Section <br /> WORK TO BE PERFORMED: <br /> �IJEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') [:1 DESTRUCTION(CHOOSE TYPE BELOW) <br /> /\ ❑SOIL BORING ❑OVER-BORE DIAMETER <br /> ❑WELL# _ ! Z ElPRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: L <br /> / 7-'000":!F- <br /> TYPE <br /> tTYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ��_El MONITORING HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIVA: <br /> El EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS ,f�/� TYPE OF CASING: STEEL PVC 5f /, <br /> OTHER4?t r'0iP// <br /> (❑_VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL or TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes No (NOTE::MAXIMUM FREE-FA L DEPTH IS 30') _ <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS efel— <br /> El OTHER: ❑OTHER: APPROX.BORING DEPTH 4q- f T� ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED [�} �(if YES,list specifications in comment section) <br /> COMMENTS: o� �— <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all app cab alifornia Laws. p _ <br /> Signed , - -- - t4a Title/Company SJ _/ �"/y —p���/y ,/Gl�/{�/� •� <br /> Print Name G'� ���1 —L ��ie��"L Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: '/ S <br /> APPLICATION ACCEPTED BYn/v a U� d /te r t llfftgZ� DATE ISSUED l� 2? '9g AREA �1 <br /> GROUT INSPECTION BY C��r^r 1/�� � FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE UCT <br /> COMMENTS/CONDITIONS: o, �i <br /> sAN J2OU8 <br /> ACCOUNTING ONLY: AID# FAC# HF'gCT�RONM fCOUN <br /> PE CODES FEE INFO AMT REMITTED CHEC RECV'D BY DATE PERMIT/SERVICE# I <br /> 1-1'+-7 r 9-611) S S 7 , KZ- zqD g �SR#00 577y <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />