Laserfiche WebLink
y <br /> WELL M-RMIT APPLICATION FOL,./l �IT;GATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304-E. Weber, Third Fl or,31449 ton, CA,, 95202 F ILCOPI <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,pplication Is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in a Health <br /> Dingy with San <br /> Assessor's <br /> oaquln CounryDevelopment Tit/le/.)Chapter 6-1115.3 and.the Standards o�n.lopaq�u�i^n/G/o�unry Public Health Services,EnvironmentalP �H�slih Division. <br /> ,✓J%3 `/1/ ��r toss Stree ffDL 77T- <br /> ----7 -qty Zp <br /> YELL Location <br /> rROPERTY Owne <br /> dl}�d!/Y�%yu/iU Address CA(fG --Zj P y(�✓'dT�� <br /> r . — 7.7 <br /> ;S7 Contractor � Phone* <br /> ��// 4/a9S%y6LL�3�% <br /> J� - � � �� <br /> Address <br /> ;onsultant/Sub Contractor Y ,TownshipRange Section <br /> SIS Coordinates:X —' <br /> /YORK TO BE PERFORMED: Q DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER-) 0 OVER-BORE <br /> SOIL BORING#_ D 0 PRESSURE GROUT <br /> yW ELL �r Grout Spedficat ons: <br /> *other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATI NS MULTIPLE CASINGS?Q YES 0 NO W ELL CASING DIA <br /> MONITORING HOLLOW STEM DIA,OF BOREHOLE TYPE OF CASING: 0 STEEL 17 PVC 0 OTt IER: <br /> 0 EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS TREMIE TYPE TO BE USED: 13 AUGERS 0 HOSE <br /> 13 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL <br /> a AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: 1]Yes 0 No (NOTE: MAXIMUM UM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 0 BOLTED TRAFFIC BOX or 17 STOVE PIPE <br /> 0 OTHER: p OTHER APPROX.BORING DEPTH <br /> (if YES,list specfications here):-� <br /> CONDUCTOR CASING PRO?OSED? <br /> P <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 /> Country Or�na es, Rules a egulations, and all applicable Californl tate LaJ+s• <br /> TitiefCompany G'L _/�I O/ <br /> Signe <br /> Date <br /> PrntName DEPARTMENT USE ONLY <br /> /J A <br /> SITE MAP IN UNFr IV FILE,ADDRE S:—;--= <br /> WORK PLAN DATED: o <br /> ^ , 3 Area�— <br /> Date Issued Date�� <br /> Application Accepted By Date��Final Inspection By <br /> Grout Inspection By <br /> Date <br /> Destructlon Inspection By <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AIDIr <br /> RECD 6Y DATE PERMIT/SERVICE REQUESTS INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# OO <br /> 2-j2Z SR# <br /> ( V/f/ w <br /> x_57•_._ W� WAIVER, C-57 Letter of Authorization to sign permit Encroachment doc_ <br />