Laserfiche WebLink
1 • i <br /> ' WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> ' 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> oplication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance wqh San <br /> .,oaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services.Environmental Health Divisiom <br /> Assessor's <br /> "Location .42Y (n(,''Forn lw STrr.Y Cross Streett. e 57. City Sick Te.. Zip_QSZD3 parcel#_Jy9-Q /S <br /> ROPERTYOwner_ j3ob frenco Address 711,o6 Woo.,/jW, Citysr,,kf Zip 952,07 Phone# CZo9)yJ- SLZS <br /> 57 Contractor 7 lejnn 4"crZonhs Address 1527 eresno sT�r Ciry Fresno Zip 372 LiuYSGG," Phonez (559)TG='�7oU <br /> l <br /> consultant/Sub Contractor_ - Address 25271resno Sr ttr Cityfres✓.o Lic# Phone# [5'39)TGY-7o?/ <br /> GIS Coordinates:X 'Y ,Township / Aiorrh Range 6 Ee-r Section 11 <br /> ORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH, AND-AUGE OTHER-) 0 DESTRUCTION(choose type below) <br /> f SOIL BORING# .S (HA- - N -&) 0 OVER-BORE <br /> tOWELL# 0 PRESSURE GROUT <br /> her: Grout Specifications:: <br /> MMENTS: <br /> PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA_ <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 1 SOIL BORING I HAND AUGER GROUT SPECIFICATIONS: <br /> OTHER;_e OTHER APPROX.BORING DEPTH !S1 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? - (if YES,list specifications here): <br /> COMMENTS: <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 /> ereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> � <br /> aunty Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> l�wssf. A <br /> Ined x V/�� Title/Company 7r_vJJIry4 14,0S <br /> nt Name S/� Z Y/ASK/ Date I� S7 <br /> DEPARTMENT USE ONLY <br /> ITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> `plication Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> struction Inspection By Date <br /> MMENTS/CONDITIONS: <br /> CCOUNTING ONLY: AID# <br /> E CODES FEE INFO AMOUNT REMITTED CHECK# RECO BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/27/00 <br />