Laserfiche WebLink
WELL- PERMIT APPLICATION ARM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 /> .,A 1' Lot,JC.✓ Assessors <br /> WELL Location-Mad4 - Cross Street Sacvnwtx�b2ACity�,' } Zip gS210 Parcel# C644•C SC,•1-1 <br /> PROPERTY -tt� rte <br /> Owner AQ--F-K�)E Lah11JCZq Address 1515 1w�PS�M�✓N U�b11cG(City � ZipQsZ Z Phone# a <br /> C-57 Contractor �e,�U tea ,n� Address 6a6 <I City Phone# <br /> Consultant/Sub Cntr Address City Lic# Phone# X30' �S•�y 2� <br /> GIS Coordinates:X 1o4$2%3• 1 Y u{Z-�'a-1 2`I •5 Township Z tf4 Range (1) Section <br /> ORK TO BE PERFORMED: <br /> NEW WELL/ BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER") p DESTRUCTION (choose type below) <br /> SOIL BORING# I-2 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: <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 `ff HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)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:_0 OTHER RJ K APPROX. BORING DEPTH - IU' 0 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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi es les and gulations, and all applicable California <br /> /State <br /> /Laws. <br /> ,C J � / <br /> Signed x �/ Title/Company (.`1�Z'100)� / ���✓ti /C�G. 15-14,J-,4e <br /> Print Name �r J Date iG�'J�Dy <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: VV\c`A( ��-� e I2o� �• <br /> WORK PLAN DATED: II l c� t C�` <br /> Application Accepted By LL liter Date Issued O /t /C Y Area ZL <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 /> �"tC)1t•oU r �It ay SR# 3c( g2.cd <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to Sign permit_ Encroachment doc 9/30/02 <br />