Laserfiche WebLink
San Joaquin County <br />Env nmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EN VIRONMEN'r HEALTi..f <br />PERV1T/SERmpV1 F <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 coli rrc�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 Me, S • � j Drrt1-kc' Si " Cross Street _E • LA(Aye(AVS}.City �Arv- w" -i Zip Parcel# �C <br />PROPERTY <br />Owner_ -b" V, U Ack Address .50`6'S C1 Dor-L' j{ Cit v Zi Q <br />y � p 3 Phone# L <br />C-57 Contractor t LJ�- Address II Z.SU S. F'IV16t6)U-1'�jty4 No KJ,,,16ip .'�ic# �1 X51 Phone#5 t ?ns/ <br />Consultant / Sub Cntr m'ysmu a �Apc w' Address 1.3"l SICU V -k City S �i Li,# li p"lL l Phone#_ q b '-- tCV (. <br />GIS Coordinates: <br />WORK TO BE PERFORMED <br />VEW WELL / BORING <br />0 SOIL BORING # _ <br />0 WELL #_� <br />0 "Other <br />COMMENTS <br />Township <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />Rang <br />Section <br />0 DESTRUCTION (choose type below) \Jj <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />FEE INFO <br />)WONITORING <br />"j�­IOLLOW STEM <br />u <br />DIA. OF BOREHOLEJ16� 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: � <br />DATE PERMIT / SERVICE REQUEST # <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS 5aln. y D TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL ID'3Sin' TREMIE TYPE TO BE USED: 0 AUGERS 9 -HOSE <br />0 AIR SPARGE/ OZONE <br />0 PUSH POINT (GP or CPT)GROUT <br />SEAL PUMPED: WYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS <br />0 OTHER:_0 <br />OTHER <br />APPROX. BORING DEPTH �2(� (� `D`BpLTED TRAFFIC BOX or 0 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 in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x 6LtiAl - �� �j`' Title/Company �}kq l��E�ltid S�I�tIJIJAL1Ct 1�vCt ilV fCItwtEN'lr' 1 rtAL . <br />_ T <br />Print Na <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED-: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />C - <br />DEPARTMENT USE ONLY <br />Date <br />_Date Issued_ <br />inal Inspection By <br />a_0 <br />O . 'Zv o i <br />ACCOUNTING ONLY: AID# FAC# $ <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D B� <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />zq <br />C-57 WC= WAIVER_ C-57 Letter - F Author? ti �o sign permit Encronc ment d o c <br />EHD 29-02-001 <br />6/22/04 <br />