Laserfiche WebLink
P4`'!" SAN JOAQUIN COUNTY <br /> FILE C <br /> `� ENVIRONMENTAL HEALTH DEPARTMENT r <br /> CA 95202-3029 r=�ON <br /> 600 East Main Street, Stockton, �1]���(�.� <br /> *' ., .•P Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.or_(�rf� <br /> WELL PERMIT APPLICATION JA�� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> FERIv�t1TISER�ICE� <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 Depa m��e t. <br /> 5Assessor's 3 S <br /> Well Location K 9 GOAlf L,K4 Aj-j Cross Street Nc11 y 10e)Vt City Tratr Zip Parcel# c��`/ / <br /> Property E„tdat{...nrS&1 {.Il.6*"r <br /> Owner ;.Nh t twwt�_ Address ( 7?S C rota r Ayr City/-ko 1 e b✓k Zip I you S Phone# <br /> C-57 Contractor G rt ae Tr �rl ,TK, Address 950 City M e l4i'ru 1L Zip Y Y S S? Lic# Y e-01 S Pfione <br /> Consultant/Sub Cntr A T( /}trot lAy Tot. Address 11/I Le at 4t. City A-UdeS7t- Lic# Phone .2d 1-57 f-P7.21 <br /> GIS Coordinates:X Y Township S Range SE Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> '®SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑ PRESSURE GROUT <br /> *OTHER GROUT SPECIFICATIONS <br /> ❑ EXPLOSIVES DETONATING CARD <br /> COMMENTS:_Al/ iennei 1Ayd/'0nvrcluf 401e4a 19s jVe14ct Onet Say ekN arc Irarenio% • <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _ <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3 th I" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:A <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS A114TYPE OF CASING:[ISTEEL [IPVC [IOTHER <br /> ❑VAPOR [IMUD ROTARY DEPTH OF GROUT SEAL /✓/+ TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) 1 <br /> 1POILBORING -r [:1 HAND AUGER GROUT SPECIFICATIONS /Nte4- Ot$-w4 grovf S --y � x <br /> / , <br /> OTHER: 14- d rb u ❑OTHER: APPROX.BORING DEPTH 1 D — 7 U y <br /> CONDUCTOR CASING PROPOSED ❑(ifBYESTED P�cFations inO omme `s❑tSo) PIPE <br /> COMMENTS: <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 I accordance with San Joaquin County Ordinances,Rules and a r <br /> Regulations,and <br /> /allll applicable California Laws. <br /> Signed 1I/a`I G� ( �n <br /> 1 """ Title/Company _ill✓4 �r-fe% �44T(tlS4<e-e[�e�=S T.e <br /> Print Name .A2^+41av% Glyr;06AK Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: _ l Gra YI-f- L;n e �O a d_ <br /> WORK PLAN DATED: /A U Q 71 S 1 D' .20 0 q <br /> Ll <br /> APPLICATION ACCEPTED`B''Y Y C,+nr, ,a e,(2ar+'n e-:%( DATE ISSUED 'G' 10 AREA 1 S <br /> GROUT INSPECTION BY M i &++rid, m0-6,r+nZ�r FINAL INSPECTION BY .V i� Y',d Me_4aY -n&7 DATE I-LL-Ib <br /> DESTRUCTION INSPECTION BY 1 C. f^ 1 DATE <br /> d I <br /> COMMENTS/CONDITIONS: A. U a n e m Il T d �'Y►r E o f bo r n df S d <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES EE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 3501 69.00— <br /> 03 345.00 434.OU 060178 -6 1- 4 -10 SR# 00vS?d8 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />