Laserfiche WebLink
i <br /> • V_:; CEIVi ~ San Joaquin County <br /> Environmental Health Department SITE <br /> c. AR tl 73tf#-jEast Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (�09 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> RONMEN i�EALi <br /> AOR`' PERMIT/SERVICES Well Permit Application <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 compliam.r,wish San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> //�, ( �� Assessors <br /> WELL Location 40J3q Cross Street CityS L Zip J Q526'0 Parcel#___ <br /> PROP Address Po&� l�Isz_ Cit �Owner <br /> C-57 Contractor Address City Zip Lic# Phone# <br /> 3 S�>�- � l e(�2 4671,c)-D6Consultant/Sub Cn r Ad ress Ci Lic# Phone# <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WF,�-L/BORING (CPT,GEOPRO3E,HYDROPUNCH,NAND-AUGER OTHER') p DESTRUCTION (choose type below) <br /> OIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> HYPE OF WELL INSTALLATION TYPE CONSTRUCTICN SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BCREHOLE,aIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA.: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR G MUD ROTARY DEPTH OF GROUT SEAL" TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE ?51. <br /> USH POIN (GP r CPT)GROUT SEAL PUMPED: 0 Yes ANo NOT MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Porgy <br /> �0 O-THER: 0 OTHER APPROX.BORING DEPTH �D� '� 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> I CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> Sol <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <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 in accordance with San Joaquin <br /> County O}rdJine�s�,,Rules Regulations, and all applicable California State Daws. <br /> Signed x V�� ��"�'`'� � Title/Company <br /> Print Name W 1 /L yt, - Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �l — <br /> WORK PLAN DATED: �� C' ✓ <br /> Application Accepted By W' WC <br /> (- , ffo Date Issued � Area <br /> Grout Inspection By49ate �1 Of Fi I Inspection By Date <br /> Destruction Inspectio y Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D B DAT PERMIT/SERVICE REQUEST# INVOICE <br /> 35� l y7 V, sR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Author atiafi o s4n p rmit Encroachment doc <br /> EHD 29-02-001 I <br /> 622/04 <br />