Laserfiche WebLink
SAN JOAQUIN COUNT • <br /> .•Oo <br /> w w �(]h�D ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> EIS N' , 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3449 Far:(209)468-3433 Web:www.sigov.org/ehd MITIGATION <br /> c. - P• P UNIT IV <br /> RLrFOR� ^i LUIU <br /> ENVIRONMENT HEALTH WELL PERMIT APPLICATION <br /> PERMITISERVIC5&N-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 Develo rmPent Title,chapter 9-1115.3 and the Standards of S n,Joaqum County nvironmental Health Department. <br /> �1� Ml g Assessor's <br /> Well Location _ Cross Street r r � 5City Zip Parcel# U6 SID <br /> Property '' /I Wl4 rinrti 1� <br /> Owner Y L.(.. Address — City c Q Zip Phone# LG <br /> C-57 Contractor U •Address P3 p Gity�� Lic# jPhon &--6 <br /> Consultsnt/Sub CIMr11,�Q ,�! [,l I� Addres . / 1lt'j L y�-C}a �-6.� Lic# Pho4& yyB- <br /> GIS Coordinates:3C�T 5e-4& � ,YbA'� momL ,Township Range Section <br /> VWOORK TO BE PERFORMED: P <br /> .II'I NEW fN2CGBORING(C,P,7,GEDPP�QBE FUDR U H HAgI0.AUG R,`�'ri1ER ESTR ON(CHOOSE BELOW)C (L(,tl <br /> T- ❑SOIL BORING#lYi? Y�1 V� Y�Z �.��js J P•�3 ESSU RI GRAM <br /> ❑WELL# <br /> ❑'OTHER GROUT SPE CATIONS <br /> OI <br /> 1 <br /> COMMENTS: \pZ-OIM��S . <br /> TYPE OF WELL INSTALLATION TYPE CON TR CTI JPCI ICATI N <br /> l� <br /> [-IMONITORING *OLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS[IMULTI-LEVELWELL CASING DIA: N <br /> I <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS r/ TYPE OF CASING:F1 STEEL"(PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SE1kL TR MIE TYPE BE USED;KAUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:lyes ❑No (NOTE:MAAMMU,M`FREE-FALLDEPTHIS 30') <br /> SOIL SO G El HAND AUGER GROUT SPECIFICATIONS TYCIAJAr <br /> 'OTHER: ❑OTHE APPROX.BORING DEPTH N�1 ❑BOLTED TRAFFIC BOX OR.yYSfOVE PIPE <br /> "`� /I CONDUCTOR CASING PROPOSSEEDD "• ___ (R YES,fist spedfirations m olmM aeFAlan) <br /> COMMENTS: SPr .r/I iTHL dc:: GA <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby ce t I have p pared his application and that the work will be done I accordance with San Joaquin Co my Ordinan s,Rules and <br /> Regulation an all la le Cal' rnia Laws. n -�// <br /> Signed C Ttle/Company /!l r r^G �/ M� /C1 C— <br /> Print Name Date <br /> ' II DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS C tr,IrUC Y+wl�t, <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY^ 1rI�I,L owY� DATE SUED AREA <br /> '^ <br /> GROUT INSPECTION BY 111 ALpA FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE ( ,I <br /> COMMENTSICONDITIONS: � ,L� A 7T �`�d 46 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> Zavl VA SA 15(r,? 1 SR# 6v13b <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 1115W(MB) WELL PERMIT APP <br />