Laserfiche WebLink
WELL PERMIT APPLICATION <br /> FORM SITE <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION' <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209) 488-3449 <br /> 11 <br /> Application is hereby made to San Joaquin C ON yoFa peDrmgtLE:t to construct and oRrinstall the wok described,M DATESSUThiapplirztion is made to com Bance wi h <br /> Joaquin County Development Title,Chapter 9-11'15.3 and the Standards of San Joaquin County Environmental Health Department. p t San <br /> e <br /> WELL Location r r' 1V E 'cv,_J' , Cross Street «4�Dij6x.l� [ r� 4' �Assessorsty Zip ' 4-Parcel# <br /> PROPERTY_ <br /> f <br /> Owner G t 5i~fiti•_. c,r �� /V1 1�- f� <br /> Address WrrC�tY �DL ? Zip a hone# 3 37� <br /> 4 <br /> cj <br /> C-57 Contracts s�L 1� Di-',-' <br /> p= c-�ic# on �t'!p F/ILI <br /> Consultant I Sub Cntr ��(� Address 7 S� j <br /> -�( ,L Clic#—Phone _ J7 l< � <br /> GIS Coordinates:X Y j <br /> Townshi <br /> R Range Section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) $TRUCTION <br /> D SOIL BORING# (choose a below) <br /> 11 WELL# OVER-BORE. DIAMETER ��L� <br /> D*Other d PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> 7Y <br /> _EOF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING <br /> HOLLOW STEM DIA.OF BOREHOLE? G5 ' � LTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION D AIR HAM MERIDRIVEN CASING THICKNESS <br /> 0 VAPOR �TYPE O/F CASING: D STEEL D []OTHER: <br /> OTHER: <br /> D MUD ROTARY DEPTH OF GROUT SEAL r �lfREMIE TYPE TO BE USED: LIGERS D HOSE <br /> p AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: _63p Yes p No (NOTE:, AXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 17 OTHER: 1I OTHER APPROX.80RING DEPTH ' c7 . <br /> ��D BOLTED TRAFFIC 80X or Q STOVE PIPE k <br /> ��, �e CONDUCTOR CASING PROPOSED <br /> COMMENTS: (if YES,list specifications in comment section) F <br /> C/ C '�� � <br /> NOTE: OFFS};- BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby cartify that I have prepared this application and that the work will be done in accordance with San Joaquin 1 <br /> County Ordina ces, Rules and Regulations, and all applicable California State Laws. <br /> Signed x_ , �_ 1 <br /> Title/Company -7t_7_7L <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 7Yc�) ' zs <br /> WORK PLAN DATED: <br /> Application Accepted 8y <br /> z � Dale Issued r A ea <br /> Grout Inspection 8y Date <br /> Ina!Inspection By ?`— <br /> Destruction Inspection By IF Date i <br /> COMMENTS/CONDITIONS: <br /> 1z C <br /> c. <br /> ACCOUNTING ONLY: AID#p <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3 Sa C�t7 .2z) r 0� �f 6 sR# <br /> C-57— WC--WAIVER C-57 Letter of Author at' to Sign permit Encroachment do? <br /> 9/30/02 <br />