Laserfiche WebLink
"' " ' • SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax: (209)468-3433 Web:www.sioov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> 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 compliance with San <br /> Joaquin County Development Title,chapter 9-`1115. an the Standards of San Joaquin County Environmental Health Department. <br /> -Ws <' /?, q r,. Assessors ✓t /'�� t <br /> Well Location 5 j-�L�n,C_cnv1�. Cross Street W�;J-I-- ��City Lir' Zip (�1��1''`�Parcel# I�T2 L✓1Jy/`, <br /> OwneProper `r-ft-„(G� t�..1'-t6�-�L=1'�`,^. Address d 5 N t� �S-C 0.�{p �Lt03�- �O ZIp l'J a-0 pie# <br /> C-57 Contractor; �J.-1,5L0��� 'x-dY`�UU'�t.dress r1 IqS �'l.y.`j�:Yi-u�r "�Cfitty bJ`. � '�67 d �J �S tJ fid" <br /> /�9 y � _� Lic# Phone <br /> ity a l7 Phone Cntr frMSAAddress ; —LD —[ <br /> O <br /> GIS Coordinates:X ,Y ,To ins hi Range Section <br /> !�� G <br /> WORK TO BE PERFORMED: 11, !`d�`�'i. L <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, THER-) NDESTRUCTION(CHOOSE TYPE BELOW) <br /> [I SOIL BORING# OVER-BORE DIAMETER <br /> ❑WELL# PRESSURE GROUT <br /> F1*OTHER GROUT SPECIFICATIONS <br /> COMMENTS:— 3iW MW 1ry1pJN - , 1f il <br /> - ' <br /> r/ ntu�53 m` <br /> r <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(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 38') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (ifYES,list specifications in comment settlor) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I herebyjerllhalplication and that the work willbe done 1aRegulatiawsSignedTitle/CompanyPrintN %TI^ <br /> �{{�� � / DEPAR\TM ENT USE ON\LY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: W waY�f_( ��W�Snort-j>rLu( <br /> i <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED lJ i O AREA TL <br /> GROUT INSPECTION BY FINAL INSPECTION BYDATEDATE <br /> DESTRUCTION INSPECTION BY C DATE J%l o • X <br /> COMM ENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> QL 4lob 66 61n-6— t" R#DS6 S <br /> C-57 / WC -WAIVER C57 LETTER OF AUTHO RATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2M1 11/5/07(WEB) WELL PERMIT APP <br />