Laserfiche WebLink
WELL PERMIT APPLICATION FORM SITE <br />AID# <br />SAN JOAQUIN COUNTY MITIGATION <br />PE CODES <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />AMOUNT REMITTED <br />JUN 1 5 2006 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />REC'D BY <br />(209) 468-3449 <br />INVOICE <br />ENVIROP�N/tNT HEALTH <br />PERMIT/%UNPF NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made o n 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 />n ll I p t1 Assessors <br />WELL Location25oD W, Lodi Avc. Cross StreetlA41 � City Lodi Zip (5x'12 Parcel# <br />PROPEEt TY 1 "1%0 (pllf'{'TowhQr, 5vi*ll� 59t((4" <br />Qft City/ Zip 5 Phone# 9if�-3yo—_316 <br />Owner /}KT ptfT�t3 Address ( <br />C-57 Contractor MIU61 DiNn I&A Afo" AddressZ35 G* GAi;U3 Ay(,wt City ►'1(/Ud Zipg53YO Lic#%Phone# 707 VW- 90 0 <br />Consultant / Sub Cntr A,'JS &ytronru�+� �. Addreesss�N1°�"' Pak Dr. ##5$D City P.1k Li�cA# Q$b82 Phone#5_4>476",�06Z <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />21n <br />'%NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />' , <br />SOIL BORING # CO -1103-2. C.9-3 [] OVER -BORE. <br />V <br />DIAMETER_ <br />G <br />0 WELL # [] PRESSURE GROUT <br />G <br />0 *Other GROUT <br />SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING )(HOLLOW STEM DIA. OF BOREHOLEV'1 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Yl jq <br />Itt <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS h/a TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Syr TREMIE TYPE TO BE USED: WAUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE [] PUSH POINT (GP or CPT)GROUT SEAL PUMPED: `gYes 0- No JJ(NOTE: MAXIMUM /FREE -FALL DEPTH IS 30') <br />W .' <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS �1 n � '„ k. StrvUd&//a <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 651 0 BOLTED TRAFFIC B X or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED—ho (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. p <br />Title/Company ( ( SLL_ .0P tLJ_ J 6 tW- CUP t <br />Date 6_113 6 <br />Signed <br />Print Name L��U� (-, f_i) <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />Application Accepted By t LKAn —' Date Issued 611110(, Area 9 7� <br />Grout Inspection By� Date G�lj Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS /CONDITIONS: L -0-P. S�tc 01 <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE QUEST # <br />INVOICE <br />7'_1_1_0 Y-7 0'13 <br />