Laserfiche WebLink
WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209) 468-3449 nSa NON-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 ism n c an <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location /� t` (� i r (� /y Assesso <br /> �1w ✓ ��Ctrl Cross Street�fQYli" t -qcity S fL{ Zip VCG Parcel ors. <br /> PROPERTY/ "o Me" I /; <br /> Owner /� '[� M ihIr(in Address 7�/F. I rVV r fk'C Cit �+'��-� p yS?(}p Phone* [` osles <br /> Y-�1�Q�+ZW Zi <br /> C-57 Contractor�� f�'/��/� Address-363 O�� � J yG City_��L6��LC��1 Zip�/s ZLic#7/Ilr/D Phone#��/3/o�/��F—j/G9 <br /> Consultant/Sub Cntr� � /- AddresdA7 S LAW. City:..1gC(.rkk Lim 66727 Phone0t- io-/LV6 <br /> GIS Coordinates:X__ Y ,Township Ran e <br /> 9 Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) G DESTRUCTION jchoose type below) <br /> 0 SOIL BORING# <br /> WELL# Z h. `yj S 0 OVER-BORE. DIAMETER <br /> Other 0 PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE f 0 MULTIPLE CASINGS )9 MULTI-LEVEL WELL CASING DIA: .2 <br /> .SO4.t-)4t7 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSel-(?M 7'" TYPE OF CASING: 0 STEEL PVC <br /> 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL " TREMIE TYPE TO BE USED: AUGERS G HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: HYes <br /> Q SOIL BORING 0 No (JNOTc: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 HAND AUGER GROUT SPECIFICATIONS L7yPH,�•H/./ ;eor. /- 9.4,# fp 6j�/'/1 U <br /> G OTHER:_0 OTHER APPROX.BORING DEPTH 9�1/50/ KZ <br /> � CLTED TRAFFIC BOX or G STOVE PIPE <br /> CONDUCTOR CASING PROPCSED_dL;L_(if 'fc5,list specifications in comment sectioni <br /> CCMMENTS: r�� Sr.1� lei �.n(v.a ��.Q.P� /cvr) /vz�C/M) eH% lJe�/S <br /> NOTE: OFFSITE GRINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERN]ITS. <br /> 48 WORKING HOURS i"IOTiCE REQUIRED FCR iNSPECT!CNS. <br /> I hereby certify that I have prepared this application and that the work will be done 'n accordance with San Joaquin <br /> Coun Ordinances, Rules and Regulations, and all applicable California/State Laws. r (� <br /> Signed x 1 —Title/Company <br /> Print Name 11 )5)h I`? Ka 16n l 3 0'C k Dates_` --`r <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 1-141 "'C- � jJ�/ "t, <br /> WORK PLAN DATED: 2& J Gt /Z✓�C�Z <br /> Application Accepted By /V�/G �.tAer*5or! Date Issued a 3 Q� G �yS3 <br /> —� Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'itto <br /> DA6rmit— <br /> LPEREMIT/SEIRVICE REQUEST# INVOICE <br /> 3501 M w $ 89 3032 cNo337 I14 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization sign Encroachment doc 9/30/02 <br />