Laserfiche WebLink
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.orq/ehd UNIT IV <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 Tittle,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department- <br /> Assessors <br /> �j. city i 3V 5 Parcel#rsZ Sr- 26 -0 <br /> Well Location ��5 Cross Street [ /yht(,,vo 3- L 61a Zip <br /> OwneProper✓ ✓1 O L7L II n Address 6610 �',(t'� J)U r-k1A/d j �(���� /r<L c zip q 5 36 Phone# ZQ� 36-%�d 7 <br /> C-57 Contractor ��-� � ' Address 21 G !VI S/ �fr��' City C '� Lic# ��Z33 honej�:5 c -2QQfConsultant/SubCntr 1 '1 I�� Address /cooj�'2Q)c<Ct ) �75 city(�(/���a`i� L;c# Phone `7l( �C7 <br /> GIS Coordinates:X 12�•/7 /1 TO Y 37. 37q36-7 Township J O a r Range (O �5eL S/-Section 3 <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# COVER-BORE DIAMETER 'Z.5 InC�e$ <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑*OTHER II GROUT SPECIFICATIONS <br /> COMMENTS:�eYVvlt� a�P`ICdL�ID►� 1� �Of IS MUS "I t� romkmw- / <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 /> CONDUCTOR CASING PROPOSED _ (if YES.list specifications in comment section) <br /> COMMENTS: <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,a Lapplica Callfo Laws. ) /1�/ <br /> Signed Tole/Company i l 4 C <br /> Print Name UUP l�1�{�� Date Z� <br /> `/D <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: S� `im" "'.�" <br /> WORK PLAN DATED: O <br /> APPLICATION ACCEPTED BY DATE ISSUED �IARFA l I <br /> GROUT INSPECTION BY , , f�� FINAL INSP TI BY DATE <br /> DESTRUCTION INSPECTION BY " -'o I I - DATE 24 o <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> (76-- ecl- S sR#�a�12�2s� <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGNE MIT ENCROACHMENT DOC <br /> E1,102"I 11/5107(WEB) WELL PERMIT APP <br />