Laserfiche WebLink
WELL PERMIT APPLICATION FOT(M SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work descnbed. 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 /> II // II Assessor �} <br /> WELLLocation /OSG S6,fi6DiAr+ ,,ASf•Cross Street� City 5h2-4c' Zip �7510I Parcel# J> >z'0/ <br /> ? .:j / /rew. �.� <br /> PROPERTY Owner -6 <br /> PROPERTY i i "/ ry_¢ Z"ip __S3Licp# blPhone# <br /> &S6 Y07Phone2/a <br /> ?9 0Z7I-1(o'020aC <br /> C0 <br /> C-57 Contractors! LI±t46�;,)%ddress9sO -kCityb&," <br /> Consultant/Sub Contractor X-rro ddresson L^no "CIrvnp#BCity0Q <br /> �G Lic# Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFO DESTRUCTION(choose type bel <br /> W WELL O ING(CPT,GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER') D OVER-BORE �) <br /> IL ING# CP7=2 0C,e 1a. PRESSURE GROUT <br /> 0 WELL# <br /> 'Other: Grout Specifications: h e-a+- 2rYltn-t S <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 22n/ MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA: <br /> D EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS /LA TYPE OF CASING: D STEEL 0 PVC 0 OTHER: <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL (q o- TREMIE TYPE TO BE USED: gAUGERS D HOSE <br /> 0 AIR SPARGE 41-PUSH POINT GROUT SEAL PUMPED: nXes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> &36L BORING 0 HAND AUGER GROUT SPECIFICATIONS: &Q r en - <br /> 0 OTHER:_O OTHER APPROX.BORING DEPTH /,,�L O 1� 0 BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? V4 (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 /> 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 1Laws. q [ <br /> Signed x Title/Company Df_0.VtGln Date 1to �(7 la 1J4� <br /> Print Name 'J� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 7� j / 2 002 <br /> WORK PLAN DATED: ���D — <br /> 'I f,� �(f0 v Are ( R�QC h <br /> Application Accepted Byi r\A �" /' Date Issued !1 — ` b Y <br /> Date <br /> Grout Inspection By Date Final Inspection <br /> Destruction Inspection By Date <br /> COMMENTS/CONDfTIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTEDRCHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a Cn/ �l- (l IJ K. R l oY u 1 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/27/00 <br />