Laserfiche WebLink
>' <br /> San Joaquin County <br /> Sx <br /> Environmental Health Department SITE <br /> y 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> '4 (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> uAM j <br /> Well Permit Application <br /> Z00 APR -6 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN .JO A OUIN COUNTY <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This apgf�l aa Ii{�I aOdN.NENT AL th San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health'C;`t? r dr, A � � <br /> Assessor <br /> WELL Location / �j"fin Lwyh Cross Street L� lCtvJE ityS / Zip S Parcel# 0 'Sp"I <br /> PROP <br /> OwnnerE�`I MR)R)f LVJJ,(X— Address ED ��(} � (y/,l City S1ze' /''Zip G �� Phone# Ncq �16a�lgt <br /> C-57 Contractor ) <br /> Address C' 71 City ' k <br /> f A2ip�Lic# j�Phone# ?o //7 1Q e/6 <br /> Consultant/Sub Cntr G)1�7 Address 0 /t c1J City�c# - Z Phone#,2nj C 7 / <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> `(SOIL BORING# a OVER-BORE. DIAMETER <br /> ' ELL# 22 0 PRESSURE GROUT <br /> I*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORINGHOLLOW STEM DIA.OF BOREHOLE �S"a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS S�,�k Lib TYPE OF CASING: 0 STEEL % PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL��' b/TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 YAs 0 No (NOTE: MAXIMUM/FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS PC)r t'CL►►�GI 1 �. Kl J1 l� <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 8T BOLT D TRAFFIC BOX or 0 STOVE PIPE <br /> c '^ CONDU�TOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: J(A bo'(,/\-04 'j,J� IaI 4' 1 t�ly ©1'Ailck f–y 'r e7 . Syl,l�Y1yl—e— <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 finances, Rules and Regulatio s, and all applicable California State Laws. / <br /> Signed Title/Company S�f ! fl-r C)l 0 Sr <br /> Print Name n OL Date 3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,A DRE S: <br /> WORK PLAN DATED: ' <br /> Application Accepted By Date Issued t Area&ej <br /> Grout Inspection By Date Final Inspection By Date qO <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> v-of© 4�1Sao �. a Cr, `! '�' S R# <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 />