Laserfiche WebLink
WELL r'ERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (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 Environmental Health Department. <br /> � � Assessor's <br /> WELL Location II� Cross Street S 1I11V City -A - Zip �QU�J LParcel# \ <br /> PROPERTY Owners` C t Address 161s- 1\1-,j,- 0(— t1/-31�1 Zip "' Phone (V� <br /> C-57 Contractors L _ Address L L?+et C.(-L(� City ` Zip-94S-JLic#lj DU PhoneA(-)�3 1 <br /> + r. <br /> Consultant/Sub Contractor '�i 1I Address 20 � r—�� City—�►� (" Lic# Phone -Nr <br /> Address <br /> GIS Coordinates:X Y Township Ranw� Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") DESTRUCTION (choose type below) <br /> G SOIL BORING# _ ,, OVER-BORE <br /> n WELL# L C,� }� n PRESSURE GROUT <br /> `Other: Grout Specifications: ay,fCw' <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING []HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?n YES n NO WELL CASING DIA: <br /> 0 EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> []AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER:_H OTHER APPROX. BORING DEPTH []BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: <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 /> County Ordi a ces, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company c-;S C,QA g� of , I I ,yL <br /> Print Na e G ao Date 3-S -U <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Cl U <br /> WORK PLAN DATED: <br /> Application Accepted By r / Date Issued . V Area <br /> Grout Inspection By Date 6 16 y Final Inspection By Date <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 /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ 1/25/02 <br />