Laserfiche WebLink
.n Joaquin County ALF COPY <br /> a y� Environmental Health Department bff SITE <br /> { 600 E. Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> `1F:0 Well Permit Application <br /> CSN J <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 Cc tt Development Title,Chapter 9-1115.3 a d the Standards of San Joaquin County Environmental Health Department. <br /> $�fel/ 1(l �.00EI�i D itS\I�- �� W Assessors <br /> L`E- oq_ation 7' - Cross Street S}City A Zip l� Parcel# IVA <br /> PROPERTY ++�, Wit <br /> p�, y�_ I ,, <br /> Owner C,l I(( 0-c—'-p-0 am Address ✓`J3 Wit M /no-y'City I ✓� Zipq�. _?&Pho)ne#_�1�31�14 zwo <br /> C-57 Contractor 1 Address _City � //Zip�3 Lic#`!"���R Phone#q�313 -5!b <br /> Consultant/Sub Cntr 'All AddressOI W1� _City 4 ai�ic#( Phone#5Jj0-10b3 41�#� <br /> . / II I II <br /> GIS Coordinates:X 12-1 o <br /> � zS 23 Y� �- �� ,Township_ , O()+t%- Range_ FkT Section ;:3 <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# (p 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other �1 GROUT SPECIFICATIONS <br /> COMMENTS: C'PT_ 100yj loa'� -t fly TQ I?Lb:jt'1. A4e4— 'Qaj*I' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> XSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS oy- a M111�Y <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinance , les and Regulations, and all applicable California State Laws. <br /> Signed x t �— Title/Company `,*tW- C-V()1QI47 <br /> '/fin �, ��►� r(x �� Ja <br /> Print Name ti►' 1,A-K G i L ✓(Q� Date <br /> r <br /> DEPARTMENT USE ONLY _ 7C? <br /> SITE MAP IN UNIT IV FILE,ADDRESS: oZ ('0 \J• + 4t /!c <br /> WORK PLAN DATED: 1 3 a 0 <br /> Application Accepted By 'm - -�c� µ� Date Issued 7 Area <br /> Grout Inspection By Date Final Inspection By Date <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 /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001web O 7 <br /> 6/22/04 <br />