Laserfiche WebLink
San Joaquin County <br />Environmental Health Department SITE <br />600 E. Main Street, Stockton, CA 95202-309 D C <br />IP c,��I �TIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/eha�UNIT IV <br />.... <br />Well Permit Application Well 0 5 200 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS#OM ONME-NT HEALTH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work describegEmVp(51jp� is de in compliance with San <br />Joaquin County Dev lopment Title, Chapter 9-1115.3 and the Stand rds of San Joaquin County Environmental Health epa rll(( <br />�h+ ,�, L<) zy� 3Q0�§14e'k �� �prQ o r _ Assessors <br />W LL Lo atio'tt ��z - Cross Street V City �%hC��"� ����Zip SZOL Parcel# j� A <br />PR RE TY it rffLv-rte `• rZQ 9 �I F7 O �I <br />V <br />Addre <br />Ct i `� Stv�i/�fdr; G�I I i ? <br />C-57 Contractor 4 e City_ <br />////l��yy <br />yy16Consultant /Sub Cntr%7Y, YC.) ee✓. ��hC Address PQ. 13e�r Z�iC` <br />GIS Coordinates: X Y Township <br />Range <br />--�hone# - ` 7-7v� <br />z caucs3 si c- :4z� 3/3 <br />Phone# s f%Gf S <br />Section <br />WORK TO BE PERFORMED: <br />0 NEW 7LL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) p DESTRUCTION (choose type below) <br />OIL BORING # 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />O'Other ORIGINAL GROUT SPECIFICATIONS <br />COMMENTS: <br />AID# FAC# <br />-ODES I FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />INVOICE <br />0 MONITORING 0 HOLLOW STEM <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />co42�9s <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />(� <br />0 VAPOR 0 MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE $PUSH POINT (GP or C�GROUT <br />SEAL PUMPED: 0 Yes 0 No (NOTE;MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER <br />GROUT SPECIFICATIONS C e'.1ti If Pte/ ro411 <br />0 OTHER:_0 OTHER <br />APPROX. BORING DEPTH I2 S Fr 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />Q <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />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 />l� <br />Signed x 1��� — Title/Company L� ✓/li h / p <br />Print Name l n GQ .�T,' Date G /61"-'�� / U <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 3000 1010e_)S. El Dor-ado <br />WORK PLAN DATED: /2 1 I S 1 !) <br />Date Issued J vrl e- 8 Z 00 17 Areal cS <br />= _ _ = _ _- ✓r g W a L. jy1�1 ,,Wte - 2 - Final Inspection By jY `,� /�1 L� Date 10 7,J- O 7 <br />By Date <br />33'.1MENTS 1 CONDITIONS: PT 5-Gf�Qt� <br />- _ _ : _`7%G ONLY: <br />AID# FAC# <br />-ODES I FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />3s of °� <br />374. c-0 <br />co42�9s <br />sR# s 08 92 <br />- _ WC -WAIVER_ C-57 Letter of Authorization to sigr. permit_ Encroac men oc <br />