Laserfiche WebLink
Ik <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />ORIGINAL <br />RE(4::�jgz <br />� rj�N <br />MAY 1 LUNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENS 4,RONUENT HEALTH Grp <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applic'afldri 9awpWaiince 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 - �S b r Lu inn�r�1 �, Cross Street �� i`�S� cN� City S1 LL-1Lt7. vl Zip �oiU Parcel# /Q <br />PROPER <br />Owner *CL_6e� ddress 92 jo' Vcc. t �ti tjU4 City (,102jAE r ti- Zip 7Phone# l <br />C-57 Contractor ntn Address '�D `)ylt" City.Zip 3SLic# C Phone#�c)9�Ite�ic <br />Consultant / Sub Cntr Address n City " Lic# n Phone# <br />GIS Coordinates: X Y Township Range Section <br />AID# FAC# <br />WORK TO BE PERFORMED: <br />PE CODES <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') a DESTRUCTION (choose type below) <br />AMOUNT REMITTED <br />ISOIL BORING # 9-1 ,� .L; 0 OVER -BORE. DIAMETER <br />DATE - PER # <br />a WELL # a PRESSURE GROUT <br />a *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />Z.Zzq Z <br />5-1 $LSR# <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />a MONITORING a HOLLOW STEM DIA. OF BOREHOLE_�ai/' a MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS1�jA- TYPE OF CASING: a STEEL a PVC a OTHER: <br />a VAPOR a MUD ROTA DEPTH OF GROUT SEAL i 1) TREMIE TYPE TO BE USED: a AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE PUSH POIV(GPr CPT)GROUT SEAL PUMPED: a Yes RNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOILBORING 0HANDAUGROUT SPECIFICATIONS PCfj kL"'C-k <br />a OTHER:_0 OTHER APPROX. BORING DEPTH oZS o t W Oc a BOLTED TRAFFIC BOX or a 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 />Countydinances, Rules an Regulations, and all applicable California State Laws. <br />ll <br />Signed x Title/Company �1� "� L=�ECU1 7Cr�Sfi v .31L <br />Print Name V Date 10 - OS <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IF5�6 — LD� <br />IV FILE, ADDRESS: <br />WORK PLAN DATED: ` O <br />Application Accepted By �� <br />Date IssuedTy� Area <br />Grout Inspection ByDate Final Inspection �'7 ^tL�Dateai <br />Destruction Inspection By Date <br />COMMENTS /CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE - PER # <br />INVOICE <br />Z.Zzq Z <br />5-1 $LSR# <br />C-57 / WC ✓ -WAIVER C-57 Letter of Authorization to sign permit: rf L ro ent doc l <br />EHD 29-02-001 <br />6/22/04 <br />