Laserfiche WebLink
WEL.L PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> 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 9-111`5 , 3 and the StandardsofSan Joaquin County Public Health Services, Environmental Health Division. <br /> c� 1 ( ty �\z�i cIQ I0 Parcel# ors <br /> WELL Location D(4(//yl��17 G.c�,�xrz[l�a4tR.w�/„; V2c Cross Street aur. ce �c�'v Iw2Cf \ C�L ZiP y <br /> PROPERTY Owner&v -^ rru)r c 4�. E - B` 1.�iiv. Address 6XI &I '%1,1,L G�RcJ_CitySRvI �QrP( +��,^st�y Zip Cii"WS Phone# %at'S <br /> C-57 Contractor_(IfC( _` 4\_t _ Address i�tt ,-Z-tlO City `I'�-AIne2 Zipt�_Lic# 65� �07 Phone# 1 �- "313'$a� <br /> d0 '^ 4�-- g� / p <br /> Consultants Sub Contractor �T-LS- (I Address I? kiII,Q.( "L ���' City4rl+�+ C'L ic#(s6446 Phone# <br /> GIS Coordinates: X , Y—.---, Township Range Section <br /> WORK TO BE PERFORMED: <br /> I] NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH , HAND-AUGER, OTHER') H DESTRUCTION (choose type below) <br /> OIL BORING # `'j _ ❑ OVER-BORE <br /> r, 514-L # H PRESSURE GROUT <br /> 'Other: _Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> H MONITORING H HOLLOW STEM DIA. OF BOREHOLEA\j <br /> MULTIPLE CASINGS? H YE NO WELL CASING DIA:�vU EXTRACTION H AIR HAMMER/DRIVEN CASING THICKNESTYPEOFCASING: ❑ TEEL HPVC ❑ OTHER: <br /> ❑ MUD ROTARY DEPTH OF GROUT ��❑ VAPORTREMIE TYPE TO B [] AUGERS USED : AUGERS ❑ HOSE <br /> I] AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: p Ye`s q No (/N� OTE: M{#XIMUM FREE-FALL DEPTH IS 30 ') <br /> �L BORING �H HAND AUGER I ,, GROUT SPECIFICATIONS: N�.a> Ce'' MJ2- <br /> ❑ OTHER: / .Yi OTHER Ui fT'C p>.drr 1 APPROX. BORING DEPTH— "J H BOLTED TRAFFIC BOX or U STOVE PIPE <br /> �aa ` CONDUCTOR CASING PROPOSED'+ N ( if YES, list specifications here): <br /> 'COMMENTS: &z.lrv. <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 1 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 California State Laws. <br /> rn C \ r <br /> Signed xy Tllle/Company IY04(1(� JCtey <br /> Print Name R: t3 S, A Date l 4r l <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED : n r p 1 <br /> Application Accepted By­4k \ Date Issued, Area(. D� / <br /> Grout Inspection By Date Final Inspection By Date / J <br /> Destruction Inspection By Date <br /> COMMENTS ICON DfTIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE PERMIT ) SERVICE REQUEST # INVOICE <br /> �7 (g «G oo *a� I ff� � <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to Sign permit_ Encroachment doc_ 9/27/00 <br /> E0 39ed a00-1d HIAId E£ 4E894b0Z TE : £ T 000Z / 60 /Z1 <br />