Laserfiche WebLink
�` • � EIEE COPY <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> ANA 111191i:_ <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> retephone:(209)468-3449 Fax:(209)468-3433 Web:vIi .sioov:orD/ehd UNIT IV <br /> WELL PERMIT APPLICATION ONWp <br /> NtON-REFUNDABLE PERMIT EXPIRE 1 YEAR FROM DATE ISSUE <br /> Y V X�- <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 <br /> ��D/�eVebpment Tilie,Chapter 41115.5 and the Standards of San Joaquin County Environmental Health Department, <br /> Well LocationP�J/f__�,�yIZ[L Cross Street i�ES�- II { -T <br /> Property illy <br /> ! X Zip <br /> �.�./" Pa el#rrs�50`�7 ' <br /> Owner Cly Zip �_ Phone# <br /> C37 Contactor _IlaGY <br /> S{; ; .L_(1 Address SDy Zay�"p __e,�-� aty 13�11�scY) L o a�` ` 3 l Prone� (r C �Oy CJ <br /> Cons uItant?Sub Cntr �� Address r�.i &n4gt jr <br /> aX�bT3 City <br /> GIS Coordinates:X 3�,�1 5 ,Y_ —(ZI . Z iownstlip_2-5-1Range�rGSection <br /> WORK TO BE PERFORMED: <br /> E)NEW WELUBORING(CPT.GEOPROeE.HYDROPUNCH,HANDtAUGER;OTHER'! �.pt;DESTRUCTIONS iCMOOSE TYPE <br /> ElSOIL BORINGS - OVER-BORE DIAMETER <br /> I]WELL# _� PRESSURE GROU 1 <br /> ❑'OTHER ----- GROUT SFECIFICATIONS <br /> COMMENTS:.___�4C � <br /> Tyff OF WELL W�/aTALLATION TYPE CONSTRUCTION SPECIFICATIONSJ�— <br /> JrS,`l(MCNITORI.NG / HOLLOW STEAi DIA.OF BOREHOLE p,�� 'D <br /> l n•y> �MULTIPLE CASINGS�MULTI LEVEL WELL CASING LAA <br /> 0 E%TRACTION 0 AIR HAMMER'DRIVEN CASING THICKNESS TYPE OF CASING 0 STEEL XPVC.0 OTHER V\ <br /> VAPOR ❑!,tUD ROTARY__ __ OEPTH F OUT SEAL �[_J TRILMIE TYPE TO BE.USEDXAUGERS 0 HOSE ry <br /> 0 AIR SPARGISOZONF 0 PUSI 1 10INT lGP OR CPI __ GROUT SEAL PUMPED 0 Y¢,, 0 No (NOTE:MAXIMUMS FREE-FALL DEPTH IS 31 <br /> 0 SOIL BORING 0 HANDAUGER _CROUT SPECIRCATIGNS <br /> O OTHER r ____ ❑OTHER APPROY.GORING DEPTH _ / <br /> ����_._ ❑BOLTED TRAFFIC eO.Y OR 0$TONE PIP[ <br /> :ArbtlCTnR C/SiNb rnOPDSEO /YFS. as2ca4onsm cmmrorc spCtbn) <br /> COMMENTS: -- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 1 <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 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 lappilcabte Callfo Wwsy._ <br /> Signed ��� /� �--3� _ _TtlelCompanySf' .:L_(�� <br /> Prim Name ` � _. —. Date�I <br /> DEPARTMENT <br /> USE ONLY <br /> / <br /> SITE MAP IN UNIT IV FILE,ADDRESS: G(OJV.I S •-_-Jct-�'ti �( 2—cl 6 Q <br /> WORK PLAN DATED:_..—_._-. .._...._.-_._.� p p <br /> APPLICATION ACCEPTED By DATE ISSUED Q-1 AREA O�O <br /> GROUT INSPECTION BY _. FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY _ DATE— <br /> COMMENTS/CONDITIONS: <br /> ATECOMMENTS/CONDITIONS: <br /> ialt <br /> FAC <br /> EMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 3 23 X05} <br /> C-57—jor WC v WAIVER , C57 LETTER OF AUTHORIZATION T�L1I6 y■PE IT OACHMENT DOC <br /> cHo zsol iiia;nvEa1 ■ 1 E <br /> VLN.IJ?AVY <br />