Laserfiche WebLink
0 SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> , P 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> 1 ephone: (209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> J� <br /> Po e �NK WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <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 /> �Ho N• Assessor's <br /> Well Location <br /> E� Dw.,de S�. Cross street t'+� 4- 5}• City S+uc0.fq., Zip 9f2oZ Parcel# t39-066-t1c/ <br /> Property <br /> Owner Jew• $ Sb.c.(tn vee\ Address iogb N. 8L D,-40 0. City S+ucf+� Zip GS-zeZ. Phone <br /> C-57Contractor F: eH Dr01.1 Address 21 t'o lot,rtw. 1=d. City ✓i jesv:�1t Lic# bg frlo Phone 7,012' 7t F -5B'ec <br /> tr round 2P/ <br /> Consultant/Sub Cntr Anm t�l4; 5 Address 1.111I ena;n $4. City Esau/w. Lic# Phone�oq)fr3 S'-W 8•t� <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLBORING(CPT,GEOPROBE,HYDROPU ND GEF"?Y PTDESTRUCTION(CHOOSE TYPE BELOW) ? WQ d <br /> ❑SOIL BORING# T11__ ®OVER-BORE DIAMETER 9'11 <br /> ElWELL# ❑PRESSURE GROUT <br /> El'OTHER GROUT SPECIFICATIONS Neat <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING []HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC [ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED D AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:V Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS y✓ek{- ce"-a^ t <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,Ilst spece0ons in mmment section) <br /> COMMENTS: '� �o n:�w�nn u+C 11S fo be ADO0-ye l4 l4 o�e�otr:ll:r•r, aMd L.-cl1 F'I!,)nc w/ tea} ce.wr�{_cr^y <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS a <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and <br /> /all applicable a fomf aws. <br /> Signed / L-..._. Title/Company G r2d � ZK�d I)A)w Y5-1s- <br /> Print <br /> 5-ysPrint Name Date 2 O <br /> DEPARTMENT USE ONLY r nOp� <br /> SITE MAP IN UNIT IV FILE,ADDRESS:1 (�t-I a �_ b cet-c aCp Gy <br /> WORK PLAN DATED: 12. I t-tL O V pt to rein ti(' R_a <br /> APPLICATION ACCEPTED BY ��tAA/�/•[�— C-"- DATE ISSUED f 0_1._ AREA � / � � <br /> GROUT INSPECTION BY FINAL INSPECTION BY (,A"A C4- DATE b/ 401/ � <br /> DESTRUCTION INSPECTION BY p / DATE / G <br /> COMMENTS/CONDITIONS: 61S.FA L!-- ca/Yrt1n�'i-tA,t el M 10- ( '�M,t4l J� <br /> ACCOUNTING ONL I # FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> LgoZ .60,00 otgSo.6 (�i 511 ° SR# 5�'ZtZ <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT / ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />