Laserfiche WebLink
�n Joaquin County nD Eca V <br />Environmental Health Department AUG MT�J <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGA 16N <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ENvipio VOW 4VALTH <br />Well Permit Application <br />PERMIT/SFI;yioI 2 <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 />Assessors <br />WELL Location `y�q S. Yy/a: � Sf-�- ee t- Cross Street City 4t Zip jf l 3 Parcel# ;?/1-7t3G - Z3 <br />PROPERTY <br />Owner i' (; ✓y/�c�sic.T Address 662 C-/!?* t/4 /4 City Zip ya GL-Phone#Cza4S :e T'7 -777Z <br />C-57 Contractor r r-�l 37q 5 Lies; r T � City Yallll iptl2l'Z Lic#65.3f6J Phone# tZ�q <br />Consultant / Sub Cntr C --7J-, eCK 14. 7eci. Address / I AI- fT City liPhone# (214318 e, <br />GIS Coordinates: X Y , Township Range Secti <br />WORK TO BE PERFORMED: <br />9NEW WELL/ BORING <br />HSOIL BORING # _ <br />0 WELL # <br />0 *Other <br />COMMENTS: <br />CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA, OF BOREHOLE.Z'( MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 'gPUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />$'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: _ CT »s x�i� I-✓ �'^ '? �.� : kl' <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 xII /✓/ '�'/Js� Title/Company fes: v:J - <br />Print Name h�C /7. Date 711�1'�6 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By �. 11 Date Issued �T�(� � � XbArea <br />Grout Inspection By t Date Final Inspection By Date <br />Destruction Inspection By D to t <br />COMMENTS /CONDITIONS: ��,� f i 4 <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />P <br />INVOICE <br />0113R#�1 <br />(SU <br />� � s1 � <br />CA _7 —WC -WAIVER ' 'C-57 Letter of Authorization to sign perm -Lj- Encroachment doc <br />EHD 29-02-001 <br />6/22/04 <br />