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.sigov.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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 352-75W OYP,Q NI(AH1,VA f Y5 City p Assessor's <br /> Well Location � Cross Street y E�NAL.IS Zi ��� Parcel# 255-180 <br /> Property N0&MAA1 W,N11AIIk L[Z dM�NN lu NtPI�II, <br /> S' n/ MCFIPAN'e,'j, Address 3 P� City 0 G Zip °1490 Phone# y15-25t,-igb5 <br /> Owner CE_ uE JA � ''' <br /> ����pp ,, S3o-60- <br /> C-57 Contractor RJ VnI�LIIY�'� Address 2ZD 1�,E1451-SM E'7 City WWl-A"JO Zip�Lic# N;7-33j PhhoneCZ42t <br /> Consultant/Sub Cntr SAIL Address�TooW114ITAVf S111.1�UV City �W-AMr&6D Lic# — Phone 6110 q��7-M✓ <br /> GIS Coordinates:X 'Y Township J Range 6 F11SIL Section -91 _ <br /> WORK TO BE PERFORMED: <br /> ❑NEW ELL/BORING(CPT, OPROB ,HYDROPUNCH,HAND-AUGER,OTHER`) _ DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING#T E` rl OVER-BORE DIAMETER <br /> ❑WELL# PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS N R7 empr <br /> COMMENTS:_q- 6—POPROBE BO,ed'/+ c-25 ) <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 41/ <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3.25 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: N <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS N4 TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER A14 <br /> —r-1)—1 <br /> ! <br /> ❑VAPOR �❑JMUD ROTARY DEPTH OF GROUT SEAL �✓J TREMIE TYPE TO BE USED❑AUGERSAfHOSE <br /> ❑AIR SPARGE/OZONE kUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING /❑_HAND AUGER GROUT SPECIFICATIONS N AF cEl1cN7 <br /> XOTHER:W( �'P M`� y ❑OTHER: APPROX.BORING DEPTH �7�// ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list spe^ificatio�{in comment section <br /> COMMENTS: �7FJP�IiAr-(30e/A16 WILL i-lA✓E 19MPO W9't WELD(}lhr- /S <br /> f/c-r2!5,Ae 5(I'lecw i4w F'✓1�- C 14,9 M E-7 <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 prepare this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and a applicable Cal Vo <br /> rn a Laws. <br /> Signed Title/Company 1"T C-,-0 C-1 ENVIRUNd11&VML <br /> Print Name L A 12 to`[ 5f,%A Date <br /> ` s� JDEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1rJ� <br /> WORK PLAN DATED: 2,ew <br /> APPLICATION ACCEPTED BYDAT SU 'D AREA9 <br /> � <br /> GROUT INSPECTION BYUIK� FINAL INSPECTION DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: ,lc.U� uR.., r—e,e <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 111 SR# <br /> C-57 WC -WAIVER' C5CUETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07 WELL PERMIT APP <br />