Laserfiche WebLink
oP° ,"�c. SAN JOAQUIN COUNTY <br /> ' X. if? ENVIRONMENTAL HEALTH DEPARTMEN ITE <br /> 0. 600 East Main Street, Stockton, CA 95202-3029 �IPGATION <br /> �� Telephone: (209)468-3449 Fax:(209)468-3433 Web:www.si9ov.orqle� UNIT IV <br /> »� � .�IJ L 2 9 20 U1o,�8 WELL PERMIT APPLICATION <br /> , <br /> EN`JiRONMENT 11EALTH AS/ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS4 MM11T/Q1_`RVICES <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. _ ,� jSc: a5 <br /> Assessor's."j'_j� }{ f v, <br /> Well Location� t_ n;:'1 11>164 Cross Street <br /> e17 Assessor' <br /> L City Zip�537L, Parcel# <br /> Property n ) [� ` 1 C� G !` <br /> Owner (A �� Address /Y� t)fIA6 14_ 1 i J City�oL tot_ Zip /y Phone# %)2-.55j �� 3 <br /> C17 Contractor VSSI `X III Address CJ�`(Zlj�D J /t.rL--.(1-, .-�p City W � � Lic# C 33 Phone 5;0-624( 6-) <br /> nt/Sub y <br /> ConsultaCntr �Address ( <br /> �l cV U�e1fJ�,�^y -( kll City ( �^ r NC Lic# ' Phone ; JD-6 6 3- `// <br /> L'(} <br /> GIS Coordinates:X _37r Z3ti ,Y -1_2�, t 2i[ Township a SaML, Range f!9'�,t Section Rt�7 <br /> W,,_QPRK TO BE PERFORMED: <br /> L)9 NE 11y WELL/BORING(CPT GEOPROBE,HY ROPUNCH,HAND-AUGER,OTHER') ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> (Z'SOIL BORING# (D C. •7l�'-�. ...�yt//� ��f'3 ❑ OVER-BORE DIAMETER <br /> ELL# ��/� � ��L�t�. ❑ PRESSURE GROUT <br /> ❑`OTHER RAj GROUT SPECIFICATIONS <br /> COMMENTS: �S <br /> —TYPE-GFWELL -IASTALLATFGN TYPE ------CONSTRUCT1O SPgECIFICATIONS__ <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE'-'art ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑ HOSE <br /> ❑AIR SPARGE/OZONE 34,PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> *SOIL BORING [g HAND AUGER GROUT SPECIFICATIONS �Up2��j1 V`�("'lry V�d CP vma d <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑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 t at I haapve prepared this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,an II plicable Califo is Laws. /y,, / y <br /> Signed ��^ /!' ,,, / Title/Company p�0 r G►e7to16l sr/ Fl/1 ez <br /> Print Name �Ay2—( (71 JW O/� Date <br /> DEPARTMENT USE LY 1iY��o6 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: / /J, . 6� WON <br /> WORK PLAN DATED: <br /> ib <br /> APPLICATION ACCEPTED BY DAT AREA <br /> 5 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE ��U <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> I <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 2 <br /> 8R d4RO ,461 V" <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN r <br /> E ITT DOC <br /> EHD 29-01 11/5/07(WEB) ELL PERMIT APP <br />