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 Wb�F� 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 /> < < Ic,,�,7 Assessor's 2 <br /> WELL Location_ ShOq j��(�c6 �✓�(�rn� Cross Street r�,� city. q , ZIpC p Par cel#T.t <br /> PROPERTY Owner PtL I wrt DVx�uy4►�ddress��37 E�►�r[J4� `City [LSI L Zip /�,a Phcne#aM— <br /> C�7 Contractor /1 Address �/� / C City Zip Uclt:2 hanett - - Ol7 <br /> Consultant/Sub ContractZ V1ifd_ la V ` Address IO � CIty�Qyli-Wdkic# Phone# �� �{S� l 1� <br /> GIS Coordinates:X Y ,Township Range <br /> �)J Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/.BORING(CPT GEOPROBE,HYDROP !N H, D-A GER,OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING#G I' It 0 OVER-BORE <br /> WELL# (]PRESSURE GROUT <br /> ''Other: Grout Specll7 dons: <br /> COMMENTS' �7j SI E /wrI i D�-LsZ.�'� &�► — -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE � l MULTIPLE CASINGS?o YES �10 WELLCASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS /ll/A- TYPE OF CASING: 0 STEEL Q PVC p OTHER <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 15� TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes XNo (NOTF-: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: YyIr !!l1 L7/1 <br /> 0 OTHER: ,#OTHE APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or o STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list speoficaoons here): <br /> 'COMMENTS: <br /> -- <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 /> CountyOfinances, �ulesand Regulations, and all applicable California State Law <br /> Signed x V" Title/Company D ` f {' W <br /> Print Nam vv " a�--T-�g <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: / / <br /> Application Accepted By m Date Issued oU Area 'rokty 463 <br /> Grout Inspection By Date L 00 Final inspection By Date <br /> Destruction inspection By Date <br /> COMMENTS r CONnrTIONS• ^ t p to fV-6 <br /> ACCOUNTINGONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST t# INVOICE <br /> 3 <br /> C-5/ WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br /> �9 Edd 200-1 H1�I� EEbE89b60Z Sb �0i e60�/8L/0Z <br />