Laserfiche WebLink
SAN JOAQUIN COUNTY ;� <br /> ENVIRONMENTAL HEALTH DEPARTMENT AUG e 8 20108 <br /> 600 East Main Street, Stockton, CA 95202-30291`4VI. (Otf Mr'-N'I HE ' SITE <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www-Sjgoa troy hdK RV;^1`u5'IGATION <br /> UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is he,eby 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 /> Well Location S , CrosStreet _We� Assessor's <br /> ProPanY C Y Zip <br /> i Parcel# Z <br /> � — Z <br /> Address a 1.0. <br /> City t7Y1 ZiP�-53(0� Phone <br /> C-57 Contractor Address d t6,%k �_�'�np <br /> city MQ ,`r81y 5( rhone�Q� �13—SpO� <br /> ConsultanVSub Cntrc "1 E Address � Fitp« <br /> Q �S City GPnctr Lic#`�55 2Pho 92$)yZq-SSSS <br /> GIS Coordinates:X ,Y P 2S �_ <br /> Township Range � Section _ <br /> ,WQRK TO BE PERFORMED: <br /> NEW WELLIBORlNG(CPT, EOPROB ,HYDROPUNCH,'j;;'THER-)❑SOIORIN ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SWELL# ❑OVER-BORE DIAMETER <br /> ❑'OTHER Q PRESSURE GROUT <br /> COMMENTS: r `�>�ti� GROUT SPECIFICATIONS <br /> 1 <br /> e . <br /> 1 Cjoe q t be <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 't <br /> ❑MULTIPLE CASINGS[-]MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS <br /> TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL_s f <br /> �.,�/ TREMIE TYPE TO BE USED[]AUGERS�HOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:0 Yes)(No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ND AUGER <br /> �'\ ---._�—GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH <br /> COMMENTS: \l K W L\ (\p} ` Qn CONDUCTOR CASING PROP OSEp ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE <br /> Q ( I 10iftA ions in camlection) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT rA nt e <br /> 4i WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS RMITS <br /> 1 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 nd ail appli ie California Laws. <br /> Signed 'f <br /> Title/Company $� C..(Q$U� (� t <br /> Print Name # f l JO\1Jr C <br /> tGt 67 Date �} <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: L4 'I S <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY <br /> GROUT INSPECTION BY " ' "` t DATE ISSUED AREA2 <br /> / FINAL INSPECTIOI!By <br /> DESTRUCTION INSPECTION BY DATE U C� <br /> DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO FAC# <br /> AMT REMITTED CHECK# RECV'D BY DATE <br /> C-57. 5 b� <br /> S°1 + 315 L �3 `�v� ! (, PERMITISE`RVICE# INVOICE <br /> WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT SR# �J�U� <br /> EHD 29-01 1115W M'Ee, ENCROACHMENT DOC <br /> WELL PERMIT APP <br />