COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

EG6Nt .::tY64d SAN JOAQUIN COUNTY ED •` �r, ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 APR O 9 20 SITE SITE ITE Telephone:(209)468-3449 Fax:(209)468-3433 Web:WWW,Si90y Q a/ehd UNIT IV -0 d SAN JOAQUIN CO WELL PERMIT APPLICATION ENVIRONMENTAL HEALTH DEPARTMENT NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,chapter 9.1115.3 and the Standards of San Joaquin County Environmental Health Department. Assessor's Well Location a 1002 W. ,f`- � q__ Cross Street _ f _ ___—_ City (Jnl()STG-_Zip _—_—_— Parcel#—I 2.q - Q_010 Property p� 22 11 7 �,C1 q Owner_�tCtL;o1i�orMs -- AddressU•_L� _ _L__ _ city_ NGI� --- Zip �S23LIPhoner#_/�" I !��_6�2� C-57Contractor \__ rfl-�[ �� 1i� Address of �' el � ____ City�• rale /�1��_ 7-;p 9�'3a3 Lig# &� _O TPhone ^• ./ pper�,, /� Consultant/SubCntr LN� _ Address_SO>v City _Rl�gjn l�t ILic#_ Phone 20q ?9,12raGS- GIS Coordinates:X_ --___ ,Y —_ Township .........--....___ Range---_—__Section _--_ W RK TO BE PERFORMED: NLW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ElDESTRUCTION(CHOOSE TYPE BELOW) ❑,=L BORING# ,7 [3OVER-BOREDIAMETER----_____ WELL# .. M WSJ=SL} — }— — „yam PRESSURE GROUT ©'OTHER GROUT SPECIFICATIONS_........ COMMENTS: TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING ©HOLLOW STEM DIA.OF BOREHOLE ( ��_ d MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA' ❑EXTRACTION 0 AIR HAMMER/pRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL)!9-�VC I] OTHER ❑VAPOR XMUD ROTARY_�4____ DEPTH OF GROUT SEAL ��_TREMIE TYPE TO BE USED 0 AUGERS El HOSE ❑AIR SPARGE/OZONE /❑PUSH POINT(GP OR CPT)— GROUT SEAL PUMPEDAYes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30) C3 SOIL BORING , ❑HAND AUGERGROUT SPECIFICATIONS OTHER: _L'�'��COTHER; APPROX.BORING DEPTH _ S�' � ❑BOLTED TRAFFIC BOX OR A STOVE PIPE .t COry4UCT)RGASING P OPOSED _ (If YES,list specifications In comment section) V_ COMMENTS:_&% 11 JCMA .__G _ ____ �q_(�4_ _ TT_ �_ - _._-_—------- NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS I hereby certify that I ve pr ared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and Regulations,an a Ilc 1 Cailfornia Laws. n Signed -- _-- ---------_—__--Title/Company---Lrlc ee} Print Name 1�IC� tQ� S?��.N�ciL>�D _._..._____......-.__.-.... Date__�.�108--------------- DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: —�QCLO LJ (d ---_--_— �-� Pnpy WORK PLAN DATED: APPLICATION ACCEPTED BY fiv_1 —_ _�__W_______��__ DATE ISSUED _!j1 ^L, �—__ AREA GROUT INSPECTION BY ��_ el FINAL INSPECTION BY__L01-01--_Md&u r4_ DATE _—_—__ DESTRUCTION INSPECTION BY ��—,--_ ---_ DATE__—_--_—_---1___—_—___�. COMMENTS/CONDITIONS: _--------------- ACCOUNTING --_„_,_..,-,_,,.----___ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE 'Ll e� ,geT,0& Vt�,q y 9 08 SR# 53 CSO C-57,_„_,_WC —_—_---WAIVER _--_—C57 LETTER OF AUTHORIZATION TO SIGN P R IT ---ENCROACHMENT DOC EHD 29-01 1115/07 WELL PERMIT APP TO 39Vd NOdIdO30N3 56LTGGS6OZ bb:69 800Z/69/b0