Laserfiche WebLink
►ELL PERMIT APPLICATION FORM <br />JUL 2 1 SAN JOAQUIN COUNTY <br />2006 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />EPJVIt?ONENT HEALTy04 E. Weber, Third Floor, Stockton, CA., 95202 <br />PERMIT/SEWCES (209) 468-3449 <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <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 />Assessors <br />WELL Location IZ,tQ 6, 6wl* uJA AA" Cross Street ir��//� JAZAL LYl✓ityStQCj Zip Parcel# <br />PROPE TY Owner ' Address �g�1 W. l{A,Ur�, �jE'. City LL ZipQPhone S 0 <br />�l r�� o Q C�v <br />C-57 Contractor' m Address �eb 97P� ,2u�VwucytA City VV1 ip �' fdo ic# Phone# p00�d�p-i3�l� <br />Consultant/ Sub CnAm[�Q(.� V1�%V ddress City Lic#Phone 9 -24 0 <br />1 71 dr <br />GIS Coordinates: X - , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />`NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL <br />MONITORING <br />INSTALLATION TYPE <br />(`HOLLOW STEM <br />CONSTRUCTION SPECIFICATIONS p F�ttpp <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MUL7f`LEVEL WELL CASING DIA: 7- to <br />0 EXTRACTION <br />' 0 AIR HAMMER/DRIVEN <br />CASING THICKNESS% -4 TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL "I TREMIE TYPE TO BE U ED: �4UGERSAHOSE <br />0 AIR SPARGE/ <br />OZONE 0 PUSH POINT (GP or CPT) <br />GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE FALL DEPTS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS U&at C QU,d A& <br />0 OTHER: <br />0 OTHER <br />APPROX. BORING DEPTH ft IBOLTED TRAFFIC BOX or 0 STOVE PIPE <br />Ps <br />CONDUCTOR CASING PROPOSED tit) (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: <br />OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify at I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordin es Rules and Regulations, and all applicable California State La77/�4j <br />C-4, / l - <br />Signed x�( Title/Company 1 �< �l 7j V �V��f I�ff/GGI �'^C <br />Print Name e-7 4, /L ,,Y -(n Date ccs <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADD ESS: 1210 <br />WORK PLAN DATED: ' Z(—D <br />Application Accepted By Date Issued " Z4 10 6 Area ®� <br />Grout Inspection By Date 0 & Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# 771 <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P ERVICE REQ # <br />INVOICE <br />3550 L <br />- zl . o S R# D <br />C-57 ✓ WC ✓-WAIVER C-57 Letter of Authorization to sign permit Encroac Fmen'td oc� 9/30/02 <br />