Laserfiche WebLink
M � <br /> Dq4 " •s SAN JOAQUIN COUNTY <br /> a,. <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> cq:` oRH:P Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.si.oy.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <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 1q(0-03o-a-7 <br /> Well Location II Ig60 SSi avl {Q Cross Street KO+-/n KO� Cf ParcelAssessors <br /> Property T�n 9rA- City c�'+C`'` VL zip y�3�0 Parcel 1910-o3D-ttS <br /> Owner I ahotL ,( P,j Address ?LIVI TfRfikSON P-pL City &CrAile4D Zip q5$� Phone# 303 $y' 59g'S <br /> l C-57Contractor YD Address 30!4qq eFIrlrACi (5kFSnHAsc#90'77/p <br /> Phone:6Zg030055- <br /> H <br /> Consultant/Sub Cntr V^ Address.9-alt?bA*!KA'4 W-5 LA- City SScC4154�eA-- Lic# _ Phone d71&-(079-2000 <br /> 2 Z57oI,gg 5wfc15o <br /> GIS Coordinates:X I ,Y 1033"/528%03 ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 9NEW WELLBORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# CP 1387 f.PIS$$ [1 OVER-BORE DIAMETER <br /> Lj WELL# ❑PRESSURE GROUT <br /> ❑-OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM 'DIA.OF BOREHOLE 2/1 0 MULTIPLE CASINGS❑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 '�❑/`MUD ROTARY ^,,,.�DEPTH OF GROUT SEAL 10�.Sp- aQAEMIE TYPE TO BE USEarUGERSId HOSE <br /> 0 AIR SPARGE/OZONE Da PUSH POINT(GP OR CPT)!T I GROUT SEAL PUMPED:PYYes 0 Neo (NOTE:MAX IMMUUM FREE•FJALLL DEPTH IS 30') <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONSfi <br /> 0 OTHER: ❑OTHER: APPROX.BORING DEPTH — o20O 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list spedflmdons in mmmenl section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done I accordancewith San Joaquin County Ordinances,Rules and <br /> Regulations JJandd�all applicable California Laws. <br /> Signed l/r'6wlqa1mbaCA Title/Company <br /> Print Name Chas i Lt &I/acA DateV C7//�/ I <br /> (' n DEPARTMENT USE ONLYp, / <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �.1y 'Cd - �'��• '�L��,/ <br /> WORK PLAN DATED. <br /> APPLICATION ACCEPTED BY DATE ISSUED �,d 0 AREA757 p <br /> GROUT INSPECTION BY �I�MC�� FINAL INSPECTION BY Y17Cs'7+�-C�( DATE <br /> DESTRUCTION INSPECTION BY / DATE <br /> COMMENTSICONDITIONS: _{)L-TG 'ShMo d� 'St,(J ' ! nw M'W�h-r+•r�CJD�,CU!/!✓lix.�(.C�Ar <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 9•ds PIS e4t:1,7V74 Att, I SR#00S8/I;O <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 28-01 11/5107(WE9) WELL PERMIT APP <br />