Laserfiche WebLink
Pa ..� . SAN JOAQUIN COUNTY FILE COPY <br /> Q � ENS..�ONMENTAL HEALTH DEPARTMt_NT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 %,GATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.s' � - �- IT IV <br /> F a� <br /> WELL PERMIT APPLICATION JUL 2 9 2009 COT <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISBOR3 F <br /> ONPY1EN.T f1rALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This ap HWT1���Vfei�glpliance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> //''// /� „^.,,^, Assessor's J Well Location W� y;J Cross Street 664nS City 1i' Zip c� Parcel ffz.;- <br /> Property ,, r - — <br /> Owner (� YL^tC.u' Address �. +- �a City v-a `(✓C Zip fj�3)�� Phone# ��1uq ??. <br /> C-57 Contractor c. t y� Address 950Q_ ' Ij <br /> City ( P�iYVcL Lic# /�� Phone��5-5- 7/,, ' �ft <br /> ��11 ,' �fzb- <br /> Consultant/SubCntr j�� ��)X Address�Z)2 C�`�47 ;� S�- City Lic#Phone 5-1 p-(n63 "�//P� <br /> GIS Coordinates:X 37, 7 3 c(/ Y ,Township ��C��,cr` Range Gj Section r�� <br /> YWORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT.GEOPROBE,HY p,ROPUNCH,HAND-AUGER,OTHER") ./ ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# I }c1 7() A t, /Iy '�r ❑ OVER-BORE DIAMETER <br /> / <br /> (J'WELL# _ tl/�i1 [I PRESSURE GROUT <br /> F1*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: Com.' boy-"y`p '�-- 2`}1 ` <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑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 PUSH POINT(GPO PT) GROUT SEAL PUMPED:❑Yes ❑No ((NOTE: MAXIMUMFREE-FALLDEPTH IS 30') <br /> A J1 <br /> SOIL BORING AND AUGER GROUT SPECIFICATIONS 1� 4 1 ���d 11Y1F Y,�t <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 that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,a d all applicable C,ilifornia Laws. /),,� <br /> Signed C� Title/Company P'�`C� w6 ts-r l E-c Oeo�x' <br /> Print Name �i�l ���r , Date :77tZS�a <br /> DEPARTMENT USE ONLY Z9- 6v <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATF7SE95E ej AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY 77 Ilaaon DATE is 9 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> yRla lig s 5 7-�►-0Y R#os�� <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION N RMr ENCROACHMENT D C IV <br /> EHD 29-01 11/5/07(WEB) <br /> �L E y O[ ���PPEL PERMIT APP <br />