Laserfiche WebLink
. F�axPLFRM SITE <br /> I WELL PERMIT AP MITIGATION <br /> ` ,SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 9520.2 <br /> (209) 468-3449 , <br /> 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 /> Assessors <br /> Joaquin County Development Title.Chapter 9-11,1`5.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Q fN Cross Street Ql t City 4 zip �0 Pa�el# <br /> WELL Location V 2 , <br /> Address 7y;5 Ir City iP_�I[x'hone#& <br /> PROPERTY Owner P x` 74 <br /> 5 Z ity S Zi 7Z Lic#i-5 Phone# 1 <br /> C-57 Contractor Address / Q06 <br /> Consultant I Sub Contractor ' <br /> Addressg5ZLic#�'_ hone#2* ^� <br /> Y Township Range,:, Section <br /> GIS Coordinates:X ; <br /> W K TO SE PERFORMED: a DESTRUCTION(choose type below) <br /> EW WELL 1 BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) �]OVER-BORE <br /> a SOIL BORING# ©PRESSURE GROUT <br /> WELL# Grout Specifications: <br /> 'Other- <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIrICATIONS <br /> MONITORING E <br /> f <br /> W STEM DIA.OF BOREHOLE 11 MULTIPLE CASINGS?II YES IO WELL CASING DIA:° <br /> EXTRACTION Q AAMMERIDRIVEN CASING THICKNESS D•Z TYPE OF CASING: [)STEELVC OTHER:. <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL S TREMIE TYPE TO BE USED: �UGERS ©HOSE <br /> 0 AIR SPARGE [�PUSH POINT GROUT SEAL PUMPED: 0 YesI No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING Q HAND AUGER GROUT SPEC IFICATiONS P& <br /> an <br /> p <br /> OTHER:_11 <br /> OTHER APPROXI BORING DEPTH 4 r )a1OLTED TRAFFIC BOX or II STOVE PIPE <br /> � CO UCTOR CASING PROPOSED?-(it YES,list specifications here): <br /> f C5ls. <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 /> 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. <br /> Title/Company <br /> Signed)( �- <br /> Date <br /> Print Name DEPARTMENT USE ONLY <br /> 1� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Gf' <br /> { WORKPLAN DATFD: IC d <br /> Date Issued <br /> Application Accepted By Date�� <br /> Grout Inspection By Date Final Inspection By <br /> Destruction inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# '' INVOICE <br /> 3�0 <br /> C-57 WC -WAIVER -57 Letter of Aufihoriza#ion to sign permit Encroachrnen d� ;, <br />