Laserfiche WebLink
j Joaquin County <br /> Bee <br /> �\,(I �� } <br /> 9 <br /> '­A7� Environmental Health Department 9 51T <br /> 600 E. Main Street, Stockton,CA 95202-3029 ITfGA��ON <br /> w <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd �� ' ' U {,r,�S4� <br /> N <br /> Well Permit Application �NPERM' <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. velop mt Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> � tow � Assessors O$0 O 9 <br /> WELL Location I�1 �`� � Cross Streeter I Q City Zip Parcel# <br /> OPERTT� -7 S7OwAddress <br /> C-57 Contractor Pry Ct 51ar� �(,(II ess ESSe City QIc�_ ip g141d LiC# ,v36 `87 Phone# ��D G7� y��� <br /> /1�Sz` Address 21�Z I!e� City "�l&'CyLiicc#7 7 Phone# s /O�� <br /> Consultant/Sub Cntr dz'` -L _ r _ <br /> GIS Coordinates:X Y ,Township 2 r�/ Range Section 5� <br /> WORK TO BE PERFORMED: <br /> B NEW WELL/BORING (C tG P OBE,HYDROPUNCH,HAND-AUGER,OTHER*) B DESTRUCTION (choose type below) <br /> 0 SOIL BORIIyG# 0 OVER-BORE. DIAMETER <br /> 4 WELL# 11 GROUT v 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> *Other_ <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS q <br /> 0 MONITORING ®HOLLOW STEM DIA.OF BOREHOLE B MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> B EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC BOTHER: <br /> B VAPOR B MUD ROTARY DEPTH OF GROUT SEAL 2- TREMIE TYPE TO BE USED: AUGERS B HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 9 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER: P,&-- tite OTHER APPROX.BORING DEPTH -C)�t�S B 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin ce Rules a egulations, and all applicable California St{ate, Laws. <br /> TitlelCompany <br /> Signed x <br /> Date <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 0 r t� � <br /> WORK PLAN DATED: -7 <br /> Application Accepted By <br /> Date IssuedArea 9q r <br /> Date / O Final Inspection By Date <br /> Grout Inspection By ' <br /> Destruction Inspection By J Date _ <br /> COMMENTS I CONDITIONS: G UIR�✓�CC <br /> FWACCOUNTINGONLY: FAC#UNTREMITTED CHECK# '� RECD BY DATEPERMIT/SERVICE REQUEST# INVOICEFq- Cwfin,.,.( 4"1- /zfto SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc— <br /> LHD 29-02-001web <br /> 6/22/04 - <br />