Laserfiche WebLink
0 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> LU = SAN JOAQUIN COUNTY UNIT IV <br /> �L, a ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> N 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> O NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appl'�on is Oby made to San Joaquin County for a permit to construct and/or install the work described. This ap ,Depar is made in compliance with San <br /> JoaquiaCounty Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department.Assessors <br /> z a.,_e-e Cross Street tl yl City �p Zip 9Sj y/Y/ Parcel#U43—/ �1 <br /> WELL Location a-( rl��ro/1k� <br /> PROPERTY Owner I P � � Address 46U <br /> jn PQ)f.. 4,/140 Zi <br /> Phone#� V <br /> Address � 9AeC C1, City _ <br /> hone# �- / � <br /> C-57Contractor I ZipX14 # <br /> Consultant I Sub Cntr <br /> /a(rf Address S V cu D 6 <br /> T�Lic# Phone# �I'�7 <br /> Y ,Township <br /> Range Section <br /> GIS Coordinates:X <br /> WO CTO BE PERFORMED: la DESTRUCTION(choose type below) <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') a OVER-BORE <br /> S IL BORING# a PRESSURE GROUT <br /> ELL# �'lr <br /> Grout Specifications: <br /> 'Other: <br /> COMMENTS <br /> TY E OF WELL IN ALLATION TYPE CONSTRUCTION SPECIFICATIONSCASING <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE I MU�.TIP' ELE OF CASINGSINGS'a : 0 STEELELCELL�OTHER:DIA:, _ <br /> a EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS ((�� <br /> p VAPOR p MUD ROTARY DEPTH OF GROUT SEAL 7D �S t _TREMIE TYPE TO BE USED: FALLJ*UDE HOSE <br /> p AIR SPARGE 1 Ozone O PUSH POINT GROUT SEAL PUMPED: p Yes �lo (NOTE: �, MU FREE ALC DSU IS 30') <br /> 0 SOIL BORING G HAND AUGER GROUT SPECIFICATIONS: 0V '�i I"� ��(( <br /> APPROX.BORING DEPTH -irP (1� I NJ p BOLTED TRAFFIC BOX or STOVE PIPE <br /> OTHER: D OTHER - — <br /> CONDUCTOR CASING PROPOSED?_/-4U-(if YES,list specifications here): <br /> 'COMMENTS: `p-, 1d-0l <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 /> V Titie/Company �Dn�c�r�1-I A-&e <br /> Signed x An <br /> Date <br /> Print Name ��� " I r a DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: - <br /> WORK PLAN DATED: <br /> Date Issued a O Z 2�7�f1 <br /> Application Accepted By Date <br /> Grout Inspection By n_ r- Date �-L a2 Final Inspection By <br /> Destruction Inspection By Date <br /> b S. t, Lb/ <br /> COMMENTS I CONDITIONS:O <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br />