Laserfiche WebLink
WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> 'I ,SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> N 0 V 2 9 2001 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ;UALTH <br /> (209) 468-3449 - <br /> NON-REFUNDABLE PERMIT EXPIRES't YEAR F'i20M DATE 15St1Ei] <br /> Application is Hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in Compliance with San <br /> Joaquin County Development Title.Chapter 9-1115.3 and the Standards of San Joaquin Caunry Public Health Services,Environmental Health Division. <br /> Assessar's <br /> wEi1 Location --II -- Cross street Q Gity2b r ZIP 20Ya Par�ec�(541-�� -e)- <br /> PROPERTYOwner rMGrl We (Or Address � CLr�C Cary zlp�4�y Phone# <br /> C-67 Contractor Ik11A.- ddresS $ 7 S� Q City. p_ �Ls�Ptton } / 75/0.-e" <br /> Consultant 1 Sub Contractor ll 4r7 Address2 CityLiC# 7�7� <br /> GIS Coordinates:X ,Y Township_ Range Section <br /> WORK TO BE PERFORMS!?: . <br /> 11 NEW WELL/BORING(CPT.GEOPROSE.HYDROPUNCH,HAND- UGER,OTHER-) 0 DESTRUCTION(Choose type below) <br /> ;SOIL BORING#3 p OVER-BORE <br /> a WELL# v a PRESSURE GROUT <br /> 'Other. Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> jl MONITORING Q HOLLOW STEM ❑!A OF BOREHOLE MULnPI F CASINGS?[I YES ONO WELL CASING DIA <br /> 011. <br /> a EXTRACTION []AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: U STEEL [I PVC j]OTHER:_ <br /> a VAPOR MUD ROTARY DEPTH!OF GROUT SEAL_ El') _ i'.r4t _TREMIE TYPE TO BE USED: la AUGERS 1]HOSE <br /> p AIR SPARGE PUSH POINT GROUT SEAL.PUMPED: U Yes goo (NOTE: MAXIM;Hl <br /> FREE-FALL D E1=TH 1S 30'3 <br /> SOIL BORING VIAND AUGER GROUT SPECIFICATIONS: �� 1 !w(l� .lOf ld 7:k 6%�I,Dn5, H-^0 — <br /> a OTHER: 11 OTHER APPROX.BORING DEPTH ���- __j]BOLTED TRAF-,IC BOX or p 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 /> I hemby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina s, Rules a d Regulations,and all applicable California State Laws. <br /> Signed x TitlelCompany <br /> r o <br /> Print Name I Q ( h Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: i <br /> WORK PLAN DATED: ove,-I. <br /> Application Accepted By Date Issued 3 Area C---�--- <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> IPACCOUNTING ONLY: A!❑# <br /> E CODES FEE INFO AMOUNT REMITTED CHECK# RECID BY DATE PERMIT'!SERVICE REQUEST# INVOICE <br /> �- t 1 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />