Laserfiche WebLink
• +i PQUtIy <br /> [ N JOAQUIN COUNTY SITE <br /> z: F. "EMN7MITIGATION <br /> NTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue, 3"d Floor, Stockton, CA 95202-2708 UNIT IV <br /> (AM6,j-3g428@*v:(209)468-3433• Web:www.co.san-joaquin.ca.us/ehd <br /> OQ�G j �P <br /> ENVIRONMEPWOAAA- IERMIT APPLICATION FORM <br /> PERMIT/SERVICES <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 /> Assessors <br /> WELL Location2I ( eJ—L Lod; AvP_ Cross Streets, 5r,4 Vol S4. City <br /> Zip952 N d Parcel#043. 050.013 <br /> PROPERTY Owne r_F(guc�rsP 'CjvaaCt Address7217A/.Feo.,eer Dirrve Cit�-D,f ,AL5"Phone#fa?&,563.0783 <br /> C-57 Contractor preG1510 <br /> to S,"V/1 da Address t4C0S. 7�/�yS�'l f CiityI CN Zie Lic#�Phone#6/0.237.N�7� <br /> Consultant/Sub Cntr StCoe Zvr f'/_ Address67 LgtPa, 6rdt C44 ic# -VA Phone#9.T .930D <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH, HAND-AUGER.OTHER') []DESTRUCTION(choose type below) <br /> WK OIL BORING# 3 0 OVER-BORE-DIAMETER <br /> []WELL# 0 PRESSURE GROUT <br /> []'Other: /nGrout Specifications: <br /> COMMENTS: 3 t 5 fo .2;; t%r 50, f Cn(0tj&4d/W"I-r/" .SkIL&--02f" <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ,�. S " MULTIPLE CASINGS?0 YES 9N WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS — TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS []HOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: []OTHER APPROX.BORING DEPTH oLS 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPO ED? (if YES,list specifications here): <br /> 'COMMENTS: r1-% 40 F7 �►`i -Fo a L rK e „�� <br /> v� a fl i � • <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 Ordinanc s, R les and Regulatnions, and all applicable California State Laws. <br /> Signed x_ �C �r�-�_ 't�r - 1�� Title/Company '-� + <br /> Print Name 7DOr-cf Date <br /> DEPARTMENT USE NLY <br /> SITE MAP IN UNIT IV FILE, ADD R SS: � (A-1 L <br /> WORK PLAN DATED: f C �( 1 <br /> Application Accepted By Date Issued`P_I I J 1 Area 4 <br /> Grout Inspection By Date 1e t7 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: 3 NZ 9- <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMOUNT REMITTED CHECK# Q RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> fj �� / � SR# - 7 <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD 29-02-001 WELL PERMIT SITE <br /> 8/27/2003 <br />