Laserfiche WebLink
,ORIGINAL <br />WELL PERMIT APPLICATION FPR`(4 =% <br />SAN JOAQUIN COUNTY ° <br />ENVIRONMENTAL HEALTH DEPARTMENT (EK,,,,,rJ�Ov3' MrFGATION <br />T <br />304 E. Weber, Third Floor, Stockton, CA., 952�c�g`T <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />UNIT IV <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 />l`� <br />Assessors <br />WELL Location 34% S� ``Y''y Yp�i l cD� • t Cross Street <br />--Strreet %0city Zip Parcel# 1 <br />57 1 0-10ZPROPERTY Owner T k\kOIl AddressjT_TCityLOS b10+VS Zipg1 &3�Phone# <br />/` iPS�aic#�175IdPhone ,bf`QOC-57 Contracto ` L Address7I6; C Cit % <br />( <br />h RjIfj. <br />Consultant/ Sub CnAI1Y'Q&. Vi.AM 0AVUe u.-4dress 0 � A l CitNYMPO Lic#GG Phone 4'f 1 -4 - O <br />GIS Coordinates: X Y Township Range Section I <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />XNELL -rt C4 Wim) 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />AID# FAC# <br />$'MONITORING HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z- ` <br />FEE INFO <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS L40 TYPE Of CASING: 0 STEELPVC 0 OTHER: <br />Q <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Lm4s'. 3 R gOrREMIE TYPE TO BE USED: 0 AUGERS HOSE <br />(^' <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: X_Y—es" No"� (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />S <br />�0 <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Vt k.(LT My a Vt-, <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH i!6?0 316 IOO"OLTED TRAFFIC BOX or 0 STOVE PIPE <br />r ^ <br />CONDUCTOR CASING PROPOSED Ko (if YES, list specifications in comment section) <br />COMMENTS: �- <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />LA <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />nn# <br />l' <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County O inances, Rules and Regulations, and all applicable California State Laws. <br />r <br />Signed x Title/Company o f <br />11 <br />Print Name �t ), Date kd r7 os <br />SITE MAP IN UNIT IV FILE, ADDORESS:_ <br />WORK PLAN DATED: ! -LZ -© <br />Application Accepted By. <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />Date <br />Issued l�`l�7 & S <br />inal Inspection By <br />Area <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE R # <br />INVOICE <br />SR# <br />C -57V WC v' -WAIVER At, C-57 Letter of Authorization to sign permit,/ Enc-ranehment--do-e-00' 9/30/02 <br />