Laserfiche WebLink
COPY <br /> .�- JOr FILE <br /> SAN A06N COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ... SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.s'6ov.org1ehd <br /> 4� R � UNIT IV <br /> WELL PERMIT APPLICATION <br /> MON-REFUNDABLE PERMIT EXPIRES"! YEAR FROM DATE ISSUED <br /> r Application is hereby made to San Josquin'Courity for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development TWe,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department, <br /> Well ff Assessor's <br /> Location p fN��� �� Crass Street oYYI7� City a YN Zip i��b�Id Parcel#_D C7 .Z.3—Z G <br /> Property <br /> Owner Nt+liY�tiS�s� rovcsl� Address 2Q$I Imo, lvic 14a City (71ya"A 1Ra dS Zip 4��. � Phone-# !o i 41 3(C4-id I E <br /> _ PaVk P cs��� ayrf <br /> C-57 Contractor �� Address I i 4 lbloO c+ A City RA Ytch a A Zib± <br /> ConsultantISutiCntr t>9 City' 510- 32_3y <br /> GIS Coordinates:X -5R- YAM- �� Township Range Section <br /> NRK TO BE PERFORMED: <br /> ®'NEW"LLI8ORING(CPT,GEOPRO$E,HYDROPUNCH,HAND-AUGER,OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW <br /> 0 SOIL BORING# y -4� El OVER-BORE DIAMETER <br /> R WELL# ❑PRESSURE GROUT <br /> -OTHER 5^-3 - + GROUT SPECIFICATIONS j <br /> COMMENTS: 5.-Q Vit <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑(MONITORING ❑HOLLOW STEM DLa.OF BOREHOLE Z`' <br /> ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DL4.: <br /> ❑EXTRACTION .❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF-CASING:❑STEEL [I PVC ❑ OTHER <br /> ❑VAPOR 11 MUD ROTARY DEPTH OF GROUT SEAL TREMtE TYPE TO BE USED❑AUGERS❑HOSE <br /> 0 <br /> ASR SPARGEIOZONE ®PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:.[(Yes [INo (NOTE:MAXIMUM+FREE-FALL DEPTH IS.30') <br /> M SOIL BORING '0 HAND AUGER GROUT SPECIFICATIONS N i`� GG�ri�+ (��D�'`` <br /> 1/OT.ER:'S:7i V 4 17 c'Y- ❑OTHER_ - APPROX.BORING DEPTH Z5 f <br /> CONDUC R CASING PROPOSE ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: (if YES,Ii cat 4Lin nt on <br /> NOTE: OFFS( BDRINGS REQ RE A CE S AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that f have.prepared this application and that the work will be done I accordance with San,foaquin County Ordinances,Rules and <br /> Regulation and all app able Califomi Laws. <br /> Signed �- 7itle/Company VD a-c 1'V{/tN�e {/V CSS <br /> Print Name DoY W U-24 <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: q. 5..b� <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> Q <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'O BY DATE PERMITISERVICE# <br /> ' I <br /> `��R iZ-Is-as NVOICE sR# 56�-RS <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD29.09 7115!07 .. . <br /> WELL PFRurr aoa <br />