Laserfiche WebLink
UKIuIIVf1l.. <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 7-p 304 E. Weber, Third Floor, Stockton, CA., 95202 eo N _ 0341� (209) 468-3449 • `e/�� <br /> 'Awe NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is htreby 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 /> Joaquin County Devetopment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> Q / I Assessor's <br /> WELL Location 47 3 t�"' Cross Street l! ae/ City s C/i Zip .z6 Parcel# <br /> PROPERTY Owner �GH 7��iti/1rl� ( cxrl�ty Address�G�7` ��U City/57�-� Zip 9SZc/ Phoned <br /> C-57 Contractor��OA-�/i i Addrress PG•Q6X 336 City/r.e6.4 Zip?457/Lic# /��Phoned#7�* Iq <br /> Consultant/ Gro-4 s Address/7�rb'E t n� P City/cJWc#51,W-7 Phonet fly:y -S✓�o c��, <br /> GIS Coordinates:X Y Township /V Range ro E Section 2- \vim <br /> VJ <br /> WORK TO BE PERFORMED: ( , - <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER-) (kOESTRUCTION(choose type below) �JJ <br /> 0 SOIL BORING# 0 OVER-BORE <br /> WELL# mz,�C-7 / VPRESSU E GROUT <br /> 'Other: Grout Specifications 3 S�^,X nI",T <br /> COMMENTS: (� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS \ <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?0 YES ONO WELL CASING DIA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER. �7 <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER_0 OTHER APPROX BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 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 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina ces, Rules d Regulations, and all applicable California State Laws/. <br /> Signed x TitlelCompany /�G�oe �w+•f/��/ `^ -� <br /> Print Name Ce -' e L (7'o46�ckJc Date <br /> DEPARTMENT USE ONLY <br /> � <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: O <br /> d <br /> Application Accepted By <br /> Date Issued ( W - <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By <br /> Date / <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!S RVICE REQUEST# INVOICE <br /> 3502 w� (90 — 538 C' c -2dSR# L Z <br /> r-;i7 \Alr -Ut/ATVPD r-;+7 1 ottor of Atitknri7ntinn to cinn normit Pnrrnnrhmont Anr Q/27/nn <br />