Laserfiche WebLink
WELL*RMIT APPLICATION FOM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> 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 is made in compliance with San <br /> Joaquin County Developme t TIi(tll ,ChanJpter 9-r111111,1/t�.3 and the Standards <br /> of San Joaquin County Environmental Health(,Department. <br /> WELL Location a6loro �a}Ir�San AVO YW Cross Street+-& Cit uv I p 1,5M Assessors,a0 q_Oa <br /> y Q �` YI Zi Parcel# / 2 <br /> PROPER lfu 1 Address, !JCYy� City 5 (-6 Zi 2 <br /> Owner V e'IPA- ryt, <br /> II I p95 3) Phone# <br /> C-57 Contractor - �rl li Address 41Vt r� Cit QAll /nzip`14�553—uc#451E5 Phone#`125'313-553 <br /> Consultant/Sub Cnt6 EAV,1W. 3jO dressM 4kDr,J 5v kSST, Cit htlWl llwk Li�c#Ss z Phone#5 L-674'20(;OZ <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ` NEW WELL/BORING ( PT, EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> OIL BORING# �,(j <br /> DIAMETER •LAS, �i-l(b,('�.1�� DOVER-BORE. <br /> �^IMtih '�T"'T� <br /> 0 WELL# _ 0 PRESSURE GROUT <br /> 0`Other GROUT <br /> SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS fW X11 wp <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE I,t a MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ,W0 TYPE OF CASING: 0 STEEL U PVC 0 OTHER: <br /> VAPOR XMUD ROTARY CQ't,�L/� DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS AHOSE//Oa <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED:WYets, OLNNN�o)(.NOTE: MMIMUM FREE-FALL DEPTH IS 30')/ <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS_ b/G✓1 6h- I Cyul1V gli- - <br /> 0 OTHER: _p OTHER APPROX.BORING DEPTH ISD/ _0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �(((,y0 ,C,�,O��N,��/J'JCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: Q Q!'''� Q /.b ('tips"""" <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR.ENCROACHMENT PERMITS. <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 in accordance with San Joaquin <br /> County Ordi at a tions, and all applicable Californian State Laws. <br /> Signedx Title/Company <br /> Print Name � <br /> Date E <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Z5 771' S. <br /> WORK PLAN DATED: <br /> Application Accepted By_Ll�r/y T/.G.L c(e%Sop Date Issued �//d O S Area 10- <br /> 3 <br /> Grout Inspection By _Date Final Inspection By <br /> Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# R,O D A{14 7 77 <br /> PE CODES I FEE INFO I AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3SU� 89 89�Y CN /v os <br />