Laserfiche WebLink
ORIGINAL <br />���gr�EC)WELL PERMIT APPLICATION FORM SITE <br />W�I�j SAN JOAQUIN COUNTY MITIGATION <br />PE CODES <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />AMOUNT REMITTED <br />2000 <br />MAR 3 1 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br />REC'D BY <br />EN�IRCNM SERVICES N (209) 468-3449 61 <br />PERMIT /SERVICE REQUEST # <br />p>cRM� 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 />sR# ��iO3 <br />WELL Location i4W W(Lnj" FhLAa4L jMht(At Cross Street City $TV"-UD,.i Zip 9SZ.69:- Parcel# <br />PROPERTY Owner (,LT`{ ofSi Dc i'�r.1 Address 3417 t4. EL DpRADD Si. City STDLx,4-pi j Zip 917 LIZ Phone# 2-0'1-6i34-%63 <br />C-57 Contractor s ?LAddress 231pS L1R. City Y, -t -Ul Zip'Ys-W Lic# t i Phone# -4L)R -4617 -6 t <br />2 <br />Consultant / Sub Cntr [G��r,.►F£t.OE� r 11.11... Address U LC E..-%-((LitiF_ City S t�L, ,-) Lic# Phone# <br />GIS Coordinates: X Y Township [ tJ Range 6 Section <br />WORK TO BE PERFORMED: <br />1; NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') p DESTRUCTION (choose type below) <br />[] SOIL BORING # [] OVER -BORE. DIAMETER <br />I1,WELL#(7S-1�3J�ps-t-60. US -1-90 (l t7aR «J G,' 3 �•.E Ltil� [] PRESSURE GROUT <br />T <br />[]'Other 6�(=yr.Nr, GROUT SPECIFICATIONS <br />COMMENTS: uNE o:tb"E <br />1rs> i-0 O 1 cJF 30', bd�. At+� �J� 46LDvJ ���.�•rs� v.1—i'$-GL- <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />►r <br />[] MONITORING jj�HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA: �_ <br />\ <br />[] EXTRACTION [] AIR HAMMER/DRIVEN CASING THICKNESS Sc,N. 40 TYPE OF CASING: [] STEEL fjiPVC [] OTHER: <br />[] VAPOR (] MUD ROTARY DEPTH OF GROUT SEALS TREMIE TYPE TO BE USED: J AUGERS [] HOSE <br />jf, IR SPARGE/ OZONE [] PUSH POINT (GP or CPT) GROUT SEAL PUMPED: RYes a No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />[] SOIL BORING [] HAND AUGER GROUT SPECIFICATIONS t4f-Ar tT (,StAb-i.L r <br />[] OTHER: [] OTHER APPROX. BORING DEPTH 91t' (,wo RBOLTED TRAFFIC BOX or [] 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 Regula#pns, and all applicable California State Laws. <br />Signed x� <br />Print Name) <br />Title/Company 5 t Ai-+ I <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 80 /V • <br />WORK PLAN DATED: <br />Application Accepted By Date Issued /`Q .3 i ED Area 0& <br />Grout Inspection By Date Final Inspection By Date -/{o-03 <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT /SERVICE REQUEST # <br />INVOICE <br />31 <br />sR# ��iO3 <br />C-57 V' WC V -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc ✓ 9/30/02 <br />� #03Mo5W <br />-754 <br />