Laserfiche WebLink
San Joaquin County <br />ORIGINAL <br />Environmental Health Department _' � SITE <br />600 East Main Street, Stockton, CA 95202-3029 CE U � 1TIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd I IAIIT III <br />Well Permit Application !AN 0 1 2008 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS6irUIRONMENT HEALTH <br />DDnn p� <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described: � 4j;W' &/�ip de in compliance with San <br />Joaquin Countv Develnnm--1 T ^' - ' ' " - Standards of San Joaquin County Environmental Health Department. <br />(�ry� nr r\ Assessors 7 <br />WELL Location IG �, SW Catty..► Cross Street Trrr�ry City �6IAIN ` � 4EZip �'I % Parcel# ZOq I� G I <br />PROPERTY ^ ((�� r�w���ffyy�t j (L� n� r+ "��., <br />Owner Very 0- rINI�IvaItALAddress I�5� W' II J I City. I1�/i(1� Zip `�� Phone# <br />C-57 Contractor ElzI v'Lf'J�I�LIN6_1 Address CiitttyWkLa� ip` Lic#W�7)54 Phone2` <br />n AD6760-W <br />Consultant/ Sub Cntr ��'lI'I C� Addressw wa tJVIJaiCityic#art Phone# <br />GIS Coordinates: X ' 121. JZ� Y ) ]7 Township Z ���1 f� Range 4 k t^ �� Section <br />WORK TO BE PERFORMED: <br />0 NEW LL / BORING PT, OP HYDROPUNCH, HAND -AUGER, OTHER*) `DESTRUCTION (choose type below) <br />FAC# <br />OIL BORING #� [] OVER -BORE. DIAMETER <br />FWE <br />FEE INFO AMOUNT REMITTED <br />LL #pw�bRESSURE GROUT <br />REC'D BY <br />0 *Othellr "GROUT SPECIFICATIONS <br />zqv <br />COMMENTS: 1- FA% 61046 1-b 243 <br />y� SR# o Z9 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE77.Z5 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS N 'A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL:1]7-2 Ji TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE „PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes(NOTE: MAXIMUM FREE -FALL DEPTH IS 301' <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Nes- <br />OTHER: W1W.0 OTHER APPROX. BORING DEPTH [] BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />_ <br />wp'l-L �nJ' /CONDUCTOR CASING PROPOSED � (if YES, Ii t spe(�ific tions i comment section) <br />Q WALL I' ora U/¶'Iit� Lu CTT �Fh� <br />x <br />COMMENTS: G.IN N r` <br />-';V- - <br />r <br />C n ���, 12Lr Irvel . W()V- C V7 'W f I'D V MUn \J AA, T�,� <br />PERMITS. <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMEN <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that I qave prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, les ltd Regulations, and all applicable California State Laws. <br />VILuJitT <br />t�►Signedx <br />Title/Company MN�t�-t1 <br />Print Name L � ��c t �'VA Date 26 I o� <br />V) <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: Z-11 <br />Application Accepted By. <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS / CONDITION <br />DEPARTMENT USE ONLY <br />/ • Irf% rte JOS/->lo <br />40% <br />Date Issued <br />-v <br />Date Final Inspection By--- - - -- — <br />Date .C"'--`- <br />C�fA�C <br />dmxjv <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DA EVICE REQ INVOICE <br />zqv <br />" <br />y� SR# o Z9 <br />C-57 WC= WAIVER_ C-57 Letter of Au orization to sign permit_ Encroachment doc <br />EHD 29-02-001 WEB <br />9/11/2007 rDSZ 7_-1 <br />