Laserfiche WebLink
UIF* <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT AUG D 2008 <br />600 East Main Street, Stockton, CA 95202-302$!�I0RONNIENT HE SITE <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.si oar �"6ATION <br />g IidSERVIC UNIT IV <br />WELL PERMIT APPLICATION <br />NON-REFLINDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is he,eby 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 />Well Location ' l S. tnST, �e�Q S1/ C_ Q� <br />CroFs Street T k� Assessors <br />Property � off" I dY � ZIP Parcel #2 1 – Z� <br />Owner Address a C�I,(A. q�.3(/� <br />City 0`r \ Zip � Phone S _ <br />C-67 Contractor t(1 Address 4 rhone <br />city ( nC.� LicS�55(�(116 G'` 13- 800 <br />Consultant/SubCntrC UI(Q Address_I�{� �C(lG�p((j�( City Cf�Y1�Ctt' Licg�V2pho �W0yZq–SS <br />ss <br />GIS Coordinates: X SO tJ �s _ <br />Y Township <br />2 S Range SectiontJ <br />_ <br />W RK TO BE PERFORMED: <br />"NEW WELUBORING (CPT, EOPROB HYDROPUNCH, ND AUGER, THF.R') <br />❑ SOIL BORING>r <br />WELL s <br />❑ 'OTHER <br />TYPE OF WELL <br />❑ MONITORING <br />❑ EXTRACTION <br />VAPOR <br />❑ AIR SPARGE/OZONE <br />❑ SOIL BORING <br />❑ OTHER' <br />1i.a— .. <br />INSTALLATION TYPE <br />❑ HOLLOW STEM <br />❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ OVER -BORE DIAMETER <br />❑ PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 7 t <br />❑MULTIPLE CASINGS ❑MULTI-LEVEL <br />WELL CASING DIA. _ <br />❑ AIR HAMMER/ORIVEN CASING THICKNESS_ TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />❑ MUD ROTARY DEPTH OF GROUT SEAL I <br />TREMIE TYPE TO BE USED ❑ AUGERS'�(HOSE <br />PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: ❑ Yes )(No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />, <br />AND AUGER GROUT SPECIFICATIONS <br />//❑``OTHER: APPROX. BORING DEPTH <br />CONDUCTOR CASING PROPED ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />C10� �nC� �1 �, Q1� OS <br />CL`(1 YElist sp`afinppns in com <br />4StA�S tL>��nw \��.\t n ._S 1 nytsetmon) <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 I accordance with San Joaquin County Ordinances, Rules and <br />Regulations nd all appll le California Laws. C <br />Signed Title/Company C.�tasur So <br />Print Name CC P #�/ �� <br />�O Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: L41.1 S 'M'.' M . �- <br />WORK PLAN DATED. <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMMENTSICON DITIO NS: <br />PE CODES I FEE INFO <br />3501 � <br />EH0 29-01 M5107 (WEF, <br />DATE ISSUED <br />IS7 <br />FINAL INSPECTION BY 1 <br />DATE <br />AREA�� <br />DATE <br />AMT REMITTED CHECK # RECV'D BY Ei]=L <br />�°I + 3�s L -3 �- <br />VAINER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT FAlronenu.,�. __ <br />WELL PERMI <br />