Laserfiche WebLink
ORIGINAL <br />WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY IIrer (�[I1�/ ' J ATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EA� <br />' <br />2001 304 E. Weber, Third Floor, Stockton, CA., 9520;4�� 1 � UNIT IV <br />i1EAL (209) 468-3449 <br />." ,` IBES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS VIF�UIVirb�Ic: �C�1h1/H1�E[ALTH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. Th s2tiBt4 �5 Yrfatle compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />// 1 l �1 L1 Assessors <br />IW' Wn t 67,,ft vZ At1 Pf 1B w �iy P 203 Parcel# 13571/0/5 <br />WELL Location Cross Street 1 1 h Ci Zi <br />PROPERTY / I �t L <br />Owner Al+ !,(�pglt Address 1bi 1`W, F/htfo& s+• City 51a h Zip�Yhone# �I <br />C-57 Contractor a 11 llin Address JSD AiYG%%t R(,� L _City i0 i Zip`q. 57 Lic# 1007 Phone# IU%3%�l-t/30p <br />Consultant / Sub Cntr54lYp� 5 Vlroj �l1µ�� AddreIs3S Y-) tMOM. �t� /, C� kM1 � c � Phone# <br />GIS Coordinates: X , Y Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING <br />0 SOIL BORING # _ <br />DIAMETER <br />0 WELL# <br />0 `Other <br />SPECIFICATIONS <br />COMMENTS: <br />(CPT, GEOPROBE, HYDROPUNCH. HAND -AUGER, OTHER-) <br />XbESTRUCTION (choose type below) <br />OVER -BORE. (/%/;2 <br />GRO����// <br />RESSURE GROUT( f;UU-3)J <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 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 />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: x"Yes0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS n&I C-f�+Ne+t <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 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 />1 n <br />Signed x Title/Company rro C \ <br />Print Name 12 Date 0 <br />11 DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: ! � I rI EY -ern D n t S tree <br />WORK PLAN DATED: OC -6 b Pir 2 3 z C� <br />Application Accepted By Vl erFPr, a L M &Ca r'I')2 Date Issued JCt nt)0 x!42.00 7 Area <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By V &,% r ; 4_ W,4,1 44 Date 0 d -,6 b / <br />COMMENTS I CONDITIONS: Def+,r U c� ice- A E m D P1 r �D / cl p,l J M%-� M W- M W '�f <br />EACCOUNTING ONLY: AID# F�DBY <br />PIE CODES FEE INFO AMOUNT REMITTED CHECK # RDATE�P�ERMITSERVICE REQUEST # INVOICE <br />3502"LO-00 00 `)W2 1)�Io7 SR* a04 `13 48 <br />