Laserfiche WebLink
U ISan Joaquin County � y <br /> :.a <br /> Q Environmental,Health Department SITE <br /> 600 E. Main Street Stockton CA 95202-3029 <br /> ": I Ci� MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org�ehd <br /> UNIT IV <br /> 'FOR Well Permit Application <br /> till 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 compliances with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> '',,// _ Assessors / <br /> WELL Locatioi W' (D /� _'-�• Cross Street!�!'! "'� City l fc, Zip 1C;�G Parcel#Zan S014 <br /> PROPER"'�p �. /7��pialQGL O�U y N�/�/ry/r 'Zp�� D!/ <br /> Owner C ! Address __ Cit i—�– ..o/neat "yin <br /> C-57 Contractor �e ..H`r 7� Addressgm love City ,A l.2- Zip 570 U-4 �hone#N6_31-3 Sr 00 <br /> Consultant/SubCntr_ CA(`, S Address �Sr/�1oNk iA�4� ity�.Nlrmnci"Lic# Phone U� Z <br /> GIS Coordinates:X-31 13 Y-IZI.`(ZS Township 2 S Range L Section 17 f? <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# a, /( 0 OVER-BORE. DIAMETER <br /> 0 WELL# eRESSURE GROUT <br /> 0'Other GROUT SPECIFICATIONS <br /> COMMENTS: LETS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NP TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARYDEPTH OF GROUT SEAL ( D TREMIE TYPE TO BE USED: []AUGERS �1?OSE <br /> 0 AIR SPARGE/OZONE g'PUSH POINT(GP r CPT ROUT SEAL PUMPED: 'Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,I'SOIL BORING �0 HAND AUGER GROUT SPECIFICATIONS <br /> /,I'S <br /> 0 OTHER: 0 OTHER_ APPROX.BORING DEPTHz O 0 BOLTED TRAFFIC BOX or 0 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 /> 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. <br /> Signed xrig �v ✓�ov��� Title/Company(1Po�.�,a,� – Ay_�Q ZS <br /> Print Name DJ) Lr trt',ot sir Date 7: <br /> V <br /> DEPARTMENT USE ONLY 2-1, S 9 <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Jc) . S� 1( <br /> WORK PLAN DATED: lD 2,00c / <br /> Application Accepted By Date Issued 1 Area Q <br /> Grout Inspection By D e Final Inspection By _ to <br /> Destruction Inspection By Date t T– <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 2,T0 1 '5� S: 6.359L? fs'_10-:- S R# <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 web <br /> 6/22/04 <br />