Laserfiche WebLink
WELL PERMIT APPLICATION FORM 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 EXPIRa permit to.011sul, ES 1 YEAR FROM DATE ISSUED COPY <br /> J\0plication is hereby made to San oaquin County Development T1rie,IChapte C9-11`15.3 lrand the Standards of San Joaquin Corny Public 11 the work d Health Servicesd. This )Environmental Healthn is made in Divisionmpilanos �9 San <br /> Assessor's <br /> "�� \� _ , City :I�_ Zip j S 37 b Parcel# �- o <br /> HELL Location .�� W u'r�`"�'� «N\Cross Street - <br /> D �T �co Zip9S206Phone# X35 33�y <br /> City <br /> PROPERTY Owner `C-e�wnv —Address `bOo 6n. �+ "lto goy <br /> p \�.'�=n zIP X41 ug# Phone#�\b"1-I'I <br /> CS7 Contractor V W R�\\'L\ Address <br /> 1}� 5'r. ci 'myo(,ts'�olJdt Phone#Z U°I S ZZ 4 I, 1 <br /> G2o�,� ,� t i v 1 ry <br /> Consui t I Sub Contractor Address Section <br /> Township Range <br /> GIS Coordinates:X�'Y----- <br /> WORK TO BE PERFORMED: U DESTRUCTION(choose type below) <br /> p NEW WELL/BORING(GPT <br /> GEOPROBE,HYDROPUNCH,HAND AUGER.OTHER') a OVER <br /> []SOIL BORING# 1 O Z.o t U PRESSURE GROUT <br /> AWELL# VNW O\ mut Specification: <br /> *Other: S'tSL <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATIONE CONSTRUCTION SPECIFICATIONS <br /> OW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?U YES ONO WELL CASING DIA:_ <br /> 1i MONITORING AHOLLTYPE OF CASING: U STEEL U PVC. []OTHER!_ <br /> U EXTRACTION U AIR HAMMER DRIVEN CASING THICKNESS TREMIE TYPE TO BE USED: U AUGERS U HOSE <br /> U VAPOR a MUD ROTARY DEPTH OF GROUT SEAL <br /> U AIR SPARGE U PUSH POINT GROUT SEAL PUMPED: U Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> U SOIL BORING U HAND AUGER. GROUT SPECIFICATIONS: U BOLTED TRAFFIC BOX or U STOVE PIPE <br /> U OTHER: U OTHER APPROX.BORING DEPTH <br /> CONDU TOR CASING PR`OPO\SED? (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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordjt>�ncQs,Rp`e c� e9ulations,and all applicable California State Laws. 1 <br /> \l�� �J Il TitlelCompany Ilk ) l <br /> Signed x Q 0':1. <br /> Date 3 2� <br /> Print Name 0' nJ a` <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: A-c j st 14 ?COL <br /> LCCG �u Date Issued <br /> >L�2 7 ,;,/0 S 3 <br /> Application Accepted By Final Inspection By Date <br /> Dale <br /> Grout Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS I CONDITIONS: <br /> ACCOUN71NG ONLY: AID#, <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# <br /> RECD BY DATE PERMIT t SERVICE REQUEST# INVOICE <br /> 350( r` W `39. �V U I��S�'' CtiTiZ 0 j 0 �3 OG3�3� a 9iz7i00 <br /> C-57__V- WC ✓-WAIVER— C-57 etter of Authorization to sign per fits Encroachment doc I� <br /> Ck«k s; f 17& F r 2 per" f <br /> E0 21007A HiAL:I £EbE99460Z 99:EI I00Z/BZ/Z0 <br />