Laserfiche WebLink
M� SAN JvAQUIN L O.OUNT'y <br /> L(CYtL -, LJ Ef^"h1l—\TR"vlEi`v <br /> afTE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone: (209.1468-3449 Fax:(209)468-3433 Web:www.s'gov.org/ehd <br /> UNIT IV <br /> 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 compliance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> L•: <br /> Assessor's <br /> Well Location !c1`jl �: Cross Street VA y� 'w4itn,�:.�c City Zip Parcel# <br /> Property t <br /> Owner t� ;��}.r i-- < .- Address Z 33C v tk i-::.c,t Leo W City l-"M , Zip Phone# <br /> C-57 Contractor �`�i � y�, �T Address "t'�� it­,�; i�� Cityt"Ea�,-,ems Lic#`IES 1��. Phone <br /> r-`» r� <br /> Consultant/Sub Cntr� AT <br /> sr,Cie _ Address WbtS 5 v cllltri Nt Lie tom'�a Ei Z Phone -Z3,52`1.4--itm, tt t <br /> GIS Coordinates:X Y — Township Range Section <br /> WORK TO BE PERFORMED: <br /> Z]NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> Z SOIL BORING# L ❑OVER-BORE DIAMETER <br /> ❑WELL# TSD ❑PRESSURE GROUT <br /> ❑"OTHER GROUT SPECIFICATIONS <br /> COMMENTS: ,.haw ,0 :cx o , �& ?10�.f ov `l\ to 4j. c�t v •�— 1 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z-S' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL F PVC ❑ OTHER .0 <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL -TG t> TREMIE TYPE TO BE USED❑AUGERS 4 HOSE <br /> ❑AIR SPARGE/OZONE ®PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:P Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ER'SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS - $:- <br /> i/� <br /> ❑OTHER: POTHER: �Gu APPROX.BORING DEH PTI OOT 't'i t9 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED __ (if YES.list specifications in comment section) \ <br /> COMMENTS: A1­11-A ell-, <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT ?ERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 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 allapplicableCalifornia Laws. <br /> Signed .c^:drr / Title/Company Q�E4.., ri-Poe:, <br /> Print Name �s x�,2d 3 �c i-i�-+„ t Date 1 3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: y7 <br /> APPLICATION ACCEPTED BY �4 � ' r DATE ISSUED l D GQ AREA <br /> GROUT INSPECTION BY !�L"t FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: ?Tt, <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT!SERVICE INVOICE <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT -NCROACHMENT DOC <br /> EHD 2"1 11/5/07(WEB) WELL PERMIT APP <br />