Laserfiche WebLink
WELL PERMIT APPLICATION FORM SITE <br /> �lSAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNITIV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (� (209) 468-3449 FILL buri <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 Develnnmant Titio nhnntar q-1115 1 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location Coss Street ty Zip /S3 x° Parcel# a�09'OSO-08 <br /> PROPERTY c� /� �� 9 3� �_/ <br /> Owner7R(MA(ZI( (�Nt�7Ut//T£ �Address3/XO Tj{�`/ �u 57�, gcityT Y Zip s Phone#;06 -- 83 s a <br /> C-57 Contractor GREG& -D21u1&t(a Address 95y Hot-)E oeoq'i) CityPhone#lzs-313-5 <br /> * 21Consultant/Sub Cntr(t-AYT� 6126U� -V1,e()Wddres�`lw/1d tL 6,Jy2 PKW/CityP46;An/7wy Lic# Phone#9LS-426-2600 <br /> 1 <br /> GIS Coordinates:X ,Y Township �.5 Range Section 8 s� <br /> WORK TO BE PERFORMED: <br /> ONEW WELL I BORING (CPT,GEO ,HYDROPUNCH, HAND-AUGER,OTHER-) DESTRUCTION (choose type below) <br /> ,SOIL BORING# C3 I�e2 OVER-BORE. DIAMETER <br /> 0 WELL;9 gPRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: So/C QaFrn/(D S z R� !�QvuiFO 4F%E✓z Ss�nr/�Ln✓Cr5� s c eF.}cE <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 'oo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 30 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 /> I hereby certi hat I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi an es. Rule a Re lation , and all applicable California State Laws. <br /> Signed x Title/Company'- 66oL06<5%— CL-A'/7vj G/ldu/ 56'eU/'!�e5 <br /> Date 7— <br /> Print Name �o�AL-� �' lgSh7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: -li <br /> Application Accepted By 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 /> q ofg -3,- -03 SR# 0D3��b/ <br /> C-572WC=WAIVER_ C-57 Letter of Authorization to Sign permit_ Encroachment doc_ 9/30/02 <br />