Laserfiche WebLink
AEC Fc,- NED <br />San Joaquin County <br />Environmental Health Deparhnent N1}�Kuu <br />/ SITE <br />600 East Main Street, Stockton, CA 95202-3029 ENVIRI NMILUM,aAMN <br />(209) 468-3449 Fax: (209) 468-3433 Web: %v,,vw.sjgov.org/ehd PERM1T/SFR\/UFIT 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 />Assessors <br />WELL Location �?O8'a E• F C010AIT Sr Cross Street W /i 77-S' City S-1-t)e/GT0n1Zip 4$Z-0�- Parcel# /S3-/3 ooS <br />PROPERTY <br />Owner 6'/[LSToE�n1C2 // Address 7o/S eW0A'70n1C00A7`City SivC/C7. <br />oA% Zip 75x/ 9Phone# (;;/(;;/Z- �S% <br />/3 <br />.D <br />C-57 Con Iractor C,KGC r R/eclA l Address 9S0 WVJC-- X DA -1 CityM/SAT/A<r ip`/11ss3 Lic# /�S/GSPhone# 9.1 S�L�SyAO <br />Consultant/ Sub Cntr A7G /)fSoG,A7ES Address /I/-/ LvNE PAC," A/ City 00-b6J-io Lic# Phone# s79? -2.2- / <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL I BORING <br />p SOIL BORING # _ <br />0 WELL # <br />0 'Other <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />VER -BORE. <br />(choose type below) <br />VER -BORE. DIAMETER $ " <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS n/E,4T- CeYYCArt- <br />COMMENTS: Mme+ /7 /NS-r.4u-6> 7o De-erV or- do/yfs !}/P,Z0k /o' /n/ SofG<:n! <br />TYPE -OF INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS / r <br />ONITORING a HOLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: -1:12-- <br />0 <br />1:12_ <br />0 EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS SCH S/y TYPE OF CASING: O STEEL IfPVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: a OTHER APPROX. BORING DEPTH 9 BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMME <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 an Regulations, and all applicable California State Laws. <br />Signedx —Title/Company P'�fG-S`;/J✓�! ��YDlrJ7/�7C- <br />Print Name T,� h/.4�.vE� Date3��,1�08 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 20 a S 7Nc w.Dw9 S -f S c for_ <br />WORK PLAN DATED: I o z (To } <br />Application Accepted By �, ��... ,� Date Issued 3 �2 �og Area <br />Grout Inspection By Date Final Inspection By Date c <br />Destruction Inspection By Date <br />COMMENTS/ CONDITIONS: ' 4- <br />ACCOUNTING ONLY: AID# <br />FAC# �/ 7 <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />3�o z <br />ba•oo <br />3333 <br />(1( <br />SR# ' 3 <br />C-57_ WC_ -WAIVER_ C-57 Letter of Authorization to sign permit --"-Encroachment doc_ <br />EHD 29-02-001 WEB <br />9/1112007 <br />