Laserfiche WebLink
San Joaquin County f <br />-�f G�C�7IE�11 <br />Environmental Health Department BITE <br />' 600 E. Main Street, Stockton, CA 95202-3029 JLIN #,DATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />Well Permit Application ENVIRONMENIT HEA; T,", <br />PERR�IT,/5! �sVICLS <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 />n ` ll Assessors <br />WELL Location 21CS 5 i_ 1 V['0r/,�iJC 5? Cross Street v City -5ke 4 /w Zip 55206 Parcel# 17.5 / 2 028 <br />PROPERTY o `(� ` L ` lS� °} -Lo CC <br />Owner Q b `t � ��� � �C . Address \ "� �n G a\ City � � � Zip Phone# � � i <br />r / <br />1 611199 p, ;zro ;owes ,• Aizho Sg 'f8 S 9a� <br />C-57 Contractor f //iji�L�N� Address _ , c� City Plia ' Licg ' 'hone# <br />4�52L <br />Consultant / Sub Cntr/ /NYiee.*-,.�ti , Jog, Address P. 0,136z,4 City e ic# Phone# <br />GIS Coordinates: <br />WORK TO BE PERFORMED: <br />0 NEW,7LL / BORING <br />SOIL BORING # _ <br />0 WELL # <br />0 *Other <br />COMMENTS: <br />Y <br />Township <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />ORIGINAL <br />Range <br />Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />0 MONITORING <br />0 HOLLOW STEM <br />DIA. OF BOREHOLE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE XPUSH POINT (GP -&r -CPT) <br />GROUT SEAL PUMPED: 0 <br />Yes 0 No (NOTE;/FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS <br />!MAXIMUM <br />C ei� 4? .1 tf /7 es, &II e- <br />0 OTHER <br />OTHER <br />APPROX. BORING DEPTH <br />/ 2.7 Al, 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <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!�( - _ - Title/Company Cqh <br />Q <br />Print Name ' T (`.h v hn. Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 3 1 0 6 S. E j 1D o y -a d o <br />WORK PLAN DATED: ) 2- 115 10( - <br />Application <br />ObApplication Accepted`Bry Y t Gt 2 r; a L. me ('4 r +' ,7 e c t Date Issued Ju rt rD 0 % Area 145'? <br />Y <br />Grout Inspection By ,y+d-r; GY ihi9Y,±1 �-,, Date) o -I - U Final Inspection By i �L�Ir i Date b ` 2f -0� <br />Destruction Inspection By �� Date <br />COMMENTS / CONDITIONS:' 'r S m - <br />V 3 <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PER ERVICE REQUEST # <br />INVOICE <br />3.$0l <br />SO3 <br />89. vo 374. o <br />X85• o <br />0042894 <br />SR# 0 50 <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroac ment doc <br />EHD 29-02-001 web <br />6/22/04 <br />