Laserfiche WebLink
WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 2066 X,1 13 AM 11: 06 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE I HD L (,,I il; i C U^I*f Y . <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. i§ app ll�at�Ar14s,r�qi� Eompliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Me ISh r 1 c r c <br />��wT II_ �11 r' ` ' `Q � ssess`o�'' T <br />/� 6w'- -SRU4 CAW q5.? Parcel# 2 <br />WELL Location 4w W, %di /'tytwm Cross Street City i Zip �� 25 0 <br />PROPERTY/� t�-t- / -} p <br />Owner A;' Propml-n Address�d lA�i�GR, IOwAv►' br sV, city C ZASg2i�lyu Phone# I N- 30-3103 <br />C-57 ContractorpfecSiM� Mte)tn�1 Address loll EsS4,% Avc�.�c City (1 Zip lq?D Lic# Phone# ✓l0_ 237- y57s <br />C4 9%IL <br />Consultant /Sub Cntr,Jj( SyifOnMwMwj �vK. Add�ress�a�h p4 DP�ity Licl# Phone# 530 4W -204Z <br />GIS Coordinates: X , Y <br />Township <br />WORK TO BE PERFORMED: <br />`ANEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />SOIL BORING # CPT -1 � CPT --L <br />DIAMETER <br />0 WELL # <br />0 *Other <br />SPECIFICATIONS <br />COMMENTS: <br />Range Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. <br />[] PRESSURE GROUT C' <br />GROUT <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLEr 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: •Ila <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Aly, TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 40' TREMIE TYPE TO BE USED: 0 AUGERS `, -T`lOSE/ <br />0 AIR SPARGE/ OZONE)KPUSH POINT (GP or CPT)GROUT SEAL PUMPED: `Yes 0 No (NOTE: VAXIMUFREE-FALLDEFTH IS 30') <br />-XSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ►1ea� a i M, S 6/y) 4t j ipP�4 S 466 <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH ! r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED h 0 (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./� r <br />Signed x Title/Company �Cf27 n A (.f4yV1 p ! t N h w <br />Print Name <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />�0l0t1D <br />Application Accepted By M'k� ` Date Issued &/I 1 Area 91 <br />Grout Inspection BDate , Z� ,04, Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS/ CONDITIONS: LVe S �✓f �� <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />/ <br />OO q <br />D <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />VOICE <br />3 soy F� — - 10 3 3 14e- &b ?/,b6 <br />