Laserfiche WebLink
San Joaquin County _ <br /> Q pz� Environmental Health Department <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd �'-'T � N <br /> .,Q b,� <br /> q�JFORN Well Permit Application ENViRMivrt-i,r iii 41 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PER,`�,7rz/SFr VIrE <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 an the Standards of San Joaquin County Environmental Health Department. <br /> , p Assessors <br /> WELL Location 7 Gv // <br /> Cross Street tic)i//SP City !f /� Zip /of Parcel# or - S <br /> PROPERTY <br /> Owner T/R 6 (10 Address/622 . n City Zipn <br /> 150Phon# <br /> C-57 Contractor 67,e <br /> Address YSO ��y,.< �� City i Ti'ti=Zip "S-Lic#�OC6 fy7Phone# 3/3-5YOO <br /> Consultant/Sub Cntr Cea It` Vlews, Sty.sVI ity r/Cloty Lic## G Phone# S -��of� �eZ,�S <br /> GIS Coordinates:X 3 7 go ,Y -/a/. Township / S Range 6 6 Section 357 <br /> WORK <br /> S- <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING CPT, EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# e(X4 , e!77-T a OVER-BORE. DIAMETER <br /> 0 WELL# 7� PRESSURE GROUT <br /> O*Other GROUT SPECIFICATIONS <br /> COMMENTS: CPT OPTAt ;5 / ,1 <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 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> AIR SPARGE/OZONEUSH POINT(GP or CPT)GROUT SEAL PUMPED: Xes 0 No (NOTE: `M//AXIMUM F EEk-FALLL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS `f S /�i�T[q � /.r/�. /l Pt '4" f e- <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 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 h e prepared this application d that the work will be done in accordance with San Joaquin <br /> County Ordinance le ations I applicable California State Laws. <br /> Signed x Title/Company (vr 1111'1e-�T1 <br /> P-1 �vi"?� <br /> Print Name //� ^1y ,/ �c <br /> Date G <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED:_('t/i2wG4 <br /> Application Accepted By ntio {� Date Issued 0 5 —Area ??7 <br /> Grout Inspection By Date Final Inspection By144IL-O— Date 4 t d <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 /> X6 0 8 0� sR# o`F 3 '1 1 q <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> . .......... <br /> EHD 29-02-001 —-- <br /> 6/22/04 <br />