Laserfiche WebLink
• • <br /> WELL PERMIT APPLICATION FORM SITE <br /> REv�O MITIGATION <br /> SAI' JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> 1-p ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> GP HF SHE 5pP 304 E. Weber, Third Fl or,3toc ton, CA., 95202 <br /> pU6449 <br /> NIA KENSP <br /> EH400' 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 Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL Location /V/'K 644&,i/�,,pp G✓�f-7' Cross Street S'l'City .5TL�leMV Zip Sr�d Parcel# /3r7—o Z0—O/ <br /> PROPERTY Owner h-4,&/2e- /x+�!/�+1��Address fS <br /> iYi City_,!! Zip 471� Phone# �6 <br /> C-57 Contractor C./SC?�E {]uLGXl�Address /e�7i Gk'1fG G!/` Cit�G� Zip Lic# 7rlSJO phone# �/6 <br /> Consultant/Sub Contractorln�CO✓L Address X6/7 e4 6,CB ACity _ Lic# Phone# 9/6 OZ/—Cy'eO <br /> >�j00 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> H SOIL BORING# 0 OVER-BORE <br /> NELL# - — 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> G MONITORING HOLLOW STEM DIA.OF BOREHOLE $ MULTIPLE CASINGS?0 YES)h10 WELL CASING DIA: Z <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS C/Y elO TYPE OF CASING: a STEEL 0 PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL o-,S TREMIE TYPE TO BE USED: ,AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 4No (N/O�T.E: MAXIMUM REE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: /✓Fi/// <br /> 0 OTHER:_U OTHER APPROX.BORING DEPTH 30 TRAFFIC BOX or 0 STOVE PIPE <br /> ,CpNDUCTOR CASING PROPOSED? <br /> y (if YES,list specifications here): <br /> 'COMMENTS: Sd� Z G�. -j-•"r/�C// �=-f/ I/D W/Ytf 0.020 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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, ules nd Regulations, and all applicable California States Laws. <br /> Signed x Title/Company <br /> Print Name (/G�� � Date <br /> DEPARTMENT USE ONLY <br /> i <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: _ /__ <br /> Application Accepted By I��^�� ��✓` Date Issued— a <br /> Grout Inspection By Date Final Inspection By v ,- <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# ❑nru <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> s0( �.©U S(O=,I Y a1 bj SR# 3 6 <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to Sign permit_Encroachment doc_ 9/27/00 <br />