Laserfiche WebLink
-in Joaquin County FILE C <br /> Environmental Health Department SITE <br /> 600 E. Main Street, Stockton, CA 95202-3029 <br /> MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> P� UNIT IV <br /> Well Permit Application <br /> CPT <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appli ion 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 CountyEnvironmentalHealth Department. �' <br /> WELL Location ( (`—OC �hYI�Vh �VL Cross Street�j1"� City IY�W Zip9S?�"L Parcel#Assessor.- <br /> C 11V )emow <br /> r- <br /> PROPERY / , _ `_ �/ <br /> Owner 1� �Y tiC� `` Address�3 Vl�{h1t�I 'GeV'6-' City Lf,' I Zip95-276 Phone# 7 831 (G4�/cOC� <br /> C-57 Contractor �! fl l il' Address TIOt✓�- City F1�74- Zip yZ Lic# Phone jZ3 S13 <br /> Consultant/Sub Cnt S Address IY /A ,�..IiwY 11,�4C'City k kw(6 jc# Phone# / 3�0 -Z)y� <br /> GIS Coordinates:X 37. 437 —'Y—al. ' Z-1 ,Township Z S Range SE Section ZU <br /> WORK TO BE PERFORMED: <br /> p NEWWLL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> /00 WELL# ( , '} 9 � s 'PRESSURE GROUT <br /> 17 `Other p GROUT SPECIFICATIONS <br /> //�-� <br /> COMMENTS: L— ` T LOC-� IG �- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE2iv� p MULTIPLE CASINGS <br /> 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS—/t/ A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER- <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1 D TREMIE TYPE TO BE USED: ❑AUGERS HOSE <br /> 0 AIR SPARGE/OZONEePUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0,Y les 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> �(r501L BORING 0 HAND AUGER GROUT SPECIFICATIONS Ne�� ►v�� / ��)•"�f�{ <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH Zt7 R 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED AI-A (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 certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. f� <br /> Signed x ' ��v�� Title/Company <br /> E <br /> Print Name \���-F ! C to�G, I�'r Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: �'� W. .S' X <br /> WORK PLAN DATED: OCT' ?.400(o y^�" <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By ate i <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 /> �Ol517DJ �l� (FTt [ g•�0• SR# Q�l �� <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EH 29-02-001 web � *hCJ 7 0 7 <br /> 6/ 2/04 <br />