Laserfiche WebLink
"ISO, ,moi <br /> 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. 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,EnvironmentalAssessor SDivision. <br /> J Sa-.Ci S Gc4+16%-Zip Parcel# <br /> WELL Location Ea �-0[ � Cross Street U n i�� �' <br /> S OG L�(Y� Address City Zip Phone# <br /> PROPERTY OwnerC�it, 0 2 <br /> //'''' /� Q G-1 3'l City R�b&_zipg55-7ILic# l0"Phone J -37�-4 <br /> C-57 Contractor kVe D,, syAddress h' / /� <br /> Consultant/Sub Contractor <br /> G �C �{P�Address 1)i Oil G Pti�'''/��• City/ / 1n{y Lic# Phone U S <br /> Y ,Township <br /> Range Section <br /> GIS Coordinates:X <br /> WORK TO BE PERFORMED: 0 DESTRUCTION(choose type belQYv) <br /> EL <br /> 0 NEW WL!BORING(CPT,GEOPROBE,HYDROPUNC ,HAND-AUGER,OTHER') 0 OVER-BORE <br /> (CPT, <br /> BORING# 0 PRESSURE GROUT <br /> &WELL# W <br /> Grout Specifications: <br /> 'Other-. <br /> COMMENTS: <br /> INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS t. <br /> -n•pE OF WELL � WELL CASING DIA:, ._ <br /> ,},MONITORING ijN'tOLLOW STEM DIA.OF BOREHOLE_MULTIPLE CASINGS. 0 YES �-NO <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5-4 140 TYPE OF CASING: []STEEL g-FVC []OTHER: <br /> a VAPOR []MUD ROTARY DEPTH OF GROUT SEAL 3.-2- ,gt TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> []AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: 4jye-s []No (NOTE: <br /> MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: OLTED TRAFFIC BOX or B STOVE PIPE <br /> 0 OTHER: []OTHER APPROX.BORING DEPTH S <br /> CONDUCTOR CASING PROPOSED? IV6 (if YES,list specifications here): <br /> *COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS IN ADVOANCEENCROACHMENT <br /> FOR OACALL R QUIRED INsPEC ONS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord* es, Rules and Regulations, and all applicable California Stataw��s. <br /> Title/Company 11A Th 4 <br /> s S OG l <br /> Signed x J <br /> Date h�-2- <br /> Print Nam DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> l t �f. Vv Date Issued � I �D 03 Area. <br /> Application Accepted By Date Final Inspection By Date—. <br /> Grout Inspection By <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 /> 17 <br /> 9/27/CO <br /> C-57 WCWAIVER_ C-57 Letter of Authorization to ig er t Encroachment doc <br /> = <br />