Laserfiche WebLink
WELL PERMIT APPLICATION FuRM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby 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 Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> sSnAssessor's <br /> WELL Location Iql2-rv' 5' T � Cross Street <br /> Vc � dy- p �ZC�5 Parcel# <br /> PROPERTY Owner-64N0_ rZN2Q/yAddreess1q(Z " sv -v <br /> "wCity � Zip 5Z c Phhone#C� / <br /> C-57 Contractor [Ci-ty�C_ 172 <br /> ZLic#- y/ Phone#/f� ��/�� <br /> Consultant/Sub Contractor �' Address�0 31 �I�IU? Cih��J'� Lic# Phone#•- 7f7 7 /LyJ b <br /> GIS Coordinates:X Y Township Range Section <br /> WO TO BE PERFORMED: <br /> W WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> OIL BORING# 0 OVER-BORE <br /> ELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS /, <br /> ' <br /> ONITORING �OLLOW STEM DIA.OF BOREHOLE !!)GL(MULTIPLE CASINGS?BYES&<O WELL CASING DIA: ' <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL.,Y'feq�— TREMIE TYPE TO BE USED: R'1!CUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes ZNo (NOTE: MAXIUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Z� P> 14 7 l' " <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH I,?5; 1rtG47_ BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASIN PPOSED? (if YES,list specifications here): _ <br /> 'COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. i <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 Californian State Laws. c� <br /> Signed x <br /> Title/Company C, - ' C— <br /> Print Name lli LGrM- t-f�P Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: 7-0b0z J W L <br /> IV <br /> Application Accepted By Date Issued f Area L <br /> Grout Inspection By Date Final Inspection By Date 10 ! O'2� <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 9/27/00 <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ <br />