Laserfiche WebLink
Ppb�N FILE COPY <br /> San Joaquin County <br /> i Environmental Health DepartniQAf. ',' _ ffF�;L l►i SITE <br /> �- 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 ;, MITIGATION <br /> • —T 209)468-3449 Fax: (209)468-3433 Web: wwW. @ d UNIT IV <br /> ( ���9�'�� d�! 8� 55 <br /> /FORS Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,pplication 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 /> oaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department Assessors <br /> /S �L 9 `+'3y <br /> WELL Location M�s LO m0 oss Street • {�ov City Zip Parcel 20 -o y <br /> PROPERTY AA <br /> Owner - - Co M m�^• •�s Address 3 2 O Tia e..l ��V�• ft city ZIP iPhone# <br /> C-57 Contractor f Address 3 0 11 Twin �6 M�Yr. City Zip�00Lic#(o959 one#C53I� GZ-�j <br /> �n n( SOCA e3 4920 Kv/( eGn4V/PCit -FL�ic# n �a Phone#C <br /> Consultant/Sub CntrC Icc_y 4, Address sal ` • __�""o� <br /> �� s c nn cs <br /> GIS Coordinates:X 'Y Township 2/ti Range Section <br /> WORK TO BE PERFORMED; <br /> �[VEW WELL!BORING (CPj._GEaPRQBE,HYDRO Uf":H, HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> I7�ELL BORING#_ - _ G` o</ meq'`"'O2_ Jf'��'' 0-'// 0 OVER-BORE. DIAMETER <br /> �lo.7i L /j.r 3 9$ PRESSURE GROUT <br /> r n3 3� 12 /3:Z!$�-/?r2- GROUT SPECIFICATIONS <br /> �3 tog 2-1 <br /> COMMENTS: ?.�P <br /> 6 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2-'.' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ' TYPE OF CASING: STEcL PVC OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 6 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0,Y{es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING [HAND AUGER GROUT SPECIFICATIONS Ivo - �o-i�^�� ` <br /> �p��i OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: �OTHER�`T APPROX.BORING DEPTH G D <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 /> I hereby certify that have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina ces Ruls and Regulations, and all applicable California State Laws. <br /> Title/Company d a ✓1 <br /> Signed x <br /> l��G (tS (�Vf Date <br /> Print Name tl �4 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: OpGcw� <br /> WORK PLAN DATED: 6 'O <br /> Application Accepted By <br /> Date Issued O Area <br /> Grout Inspection By <br /> Date Final Inspection 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 /> �D l 6v io-g SR# �3y3 <br /> C-57-1 WC=WAIVER_. C-57 Letter of Authorization to sign permit_Encroachment doc_.-• <br />