Laserfiche WebLink
San Joaquin County <br /> _ - yEnvnmental Health Departments C) TE' <br /> .� <br /> '�. < 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202MIWT <br /> TION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd AUG 3 IV <br /> c'/Lrr=oYz�',P a <br /> Well Permit Application ENVIR �T; JulAITH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDFiI �VlG � <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 Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location 1&,,147-S W. CTrka Ci . P-). Cross Street city�. City Zip W40& Parcel# 1$q-7 -0 -Z$ <br /> PROPERTY <br /> Owner ,!1 _Address_LJ3- 0 W ite" <br /> D;. City4g .ej Zip ,;3fD Phone#_ (20r <br /> C-57 Contractor /111 ,1 01&_,,__Address q50 rav a <br /> 1(�. City�_Zip 9Y553 Lic#GS ku�Phane# <br /> Consultant/Sub Cntr_ _ C=fa . Address $�.'J)l SGe w Q3- City_ lo-1 Lid# Ci$O Z2`? Phone# (IZOOV611-too& <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> !B-icfEW WELL 1 BORING CP •GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") Q DESTRUCTION (choose type ) <br /> below C <br /> U-SOIL BORING# C-P�O 4 (_i I,U<i.. Q OVER-BORE. DIAMETER C <br /> Q WELL# Q PRESSURE GROUT <br /> Q"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> C <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE- 2-" Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DEA: i11A_ <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS ,I/ TYPE OF CASING; a STEEL C <br /> Q VAPOR � Q PVC 0 OTHER: <br /> Q MUD ROTARY DEPTH OF GROUT SEAL I oC9? TREMIE TYPE.TO BE USED: AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE U15—USH POINT(GP or P 4GROUT SEAL PUMPED: Q Yes T0 (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> OIL BORING Q HAND AUGER GROUT SPECIFICATIONS P_ar{�o� ?v,..a., _ C <br /> Q OTHER: Q OTHER APPROX.BORING DEPTH r Q BOLTED TRAFFIC BOX -or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED_ Li14 <br /> (if YES,list specifications in comment section) <br /> COMMENTS: L <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 Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x � Title/Company 4, ! A c F <br /> i <br /> Prins Na Date $-30--Q!� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS:__ <br /> WORK PLAN DATED-: f� ��n.��DS" <br /> Application Accepted By Date Issued � ���/ GI .Area <br /> Grout Inspection By ol Date_071- *AK K Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> Z79 3L 3 � a9 C.EJTle ;915 c.r SR# 00g373( <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />