Laserfiche WebLink
%wow, FILE COPY <br /> a <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATIONUNIT IV <br /> Z G P/5 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> �- (209) 468-3449 N <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 Environmental Health Department. <br /> �i` Assessor's 1 <br /> WELL Location 3`C'[0 �i/ l Y! —Cross Street /I / n__ /City� � / Zip a Parcel# F!� I t 0� <br /> PROPERTY Owner FY'Gtf� (V IVAJO-Y-2a Address-WT! PD 6114 144 City 4 J Chip' 4032Phone# 0 i4 to <br /> C-57 Contractor V K Address QSa �r�we City��Zip�`[Z�ZLickCPhone#lqZ�,,313-79 <br /> Consultant/Sub Cntr 0"�✓ ess Ci Lic#R&#j29 Phone#Ajb -V?Q <br /> Parkw 'p- <br /> GIS Coordinates:X ,Y ,Town hip �� ange �-lE Section. <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING( PT EOPROBE,( YDROPUNC HAND-AUGER,OTHER*) p DESTRUCTION(choose type below) <br /> OIL BORING# 0 OVER-BORE <br /> �-r– p WELL# Q PRESSURE GROUT <br /> 'Other: Z Cr t V 1.0 e S �s0� AW 4'd-"rate– DzkvGrout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �(� Lv <br /> Q MONITORING a HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS ULTI-LEVEL*ELL CASING DIA: <br /> �e� <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASIN -i,p�!ijl THS <br /> Q VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: . AUGERS a HOSE <br /> Q AIR SPARGE/Ozone Q PUSH POINT GROUT SEAL PUMPED: a Yes Q No (NOTE: MAXIMUM FRELE-FA L DEPTH IS 30') <br /> �t r <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: CA <br /> LAI L 7 Wtr <br /> 0 OTHER: ` bTHER C-F C APPROX.BORING DEPTH <br /> ,_(( <br /> CONDUCTOR CASING PROPOSEP? (if YES,list specifications here): <br /> 1w <br /> 'COMMENTS: dA <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 Or es, Rules and Regulations, and all applicable California//State Laws. <br /> Signedx �— Title/Company .V•Z/50 , ✓H� < �H <br /> Print Name ak—xdi4 7 "l Date a <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3( TO f <br /> WORK PLAN DATED: <br /> Application Accepted By. Date Issued w Area v� <br /> Grout Inspection By Date Final Inspection By ate <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 /> 5� 81o3 E--Ib SR# 0150151? <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br />