Laserfiche WebLink
• • FILE COPY <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 Q� <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 n <br /> Joaquin County Developmen Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> 9dp/h kweS SII bn Zi [Sp��Parcel#oU�j''/(O�"{� � <br /> WELL Lowtlon 5�5� 4Cr r rC 1 � Cross Street City p <br /> Set !pq 1410 D-/f4 C.('pge Address 5rt �- CityZip Phone#c�D"75- <br /> PROPERTY <br /> 75 -50.35 <br /> PROPERTY Ownerp 1`r d C -�y��, y! e <br /> C-57 Contractor 1-r ' N Address I� J S�nr,�"" Ciry-15/..J/ Zip/5bY Lic oY Phone#26 a�� 1� <br /> 4d(t /W'"� Q R/6 & �GCPM � Lic 63 Phone# <br /> Consultant/Sub Contractor VIV V� Address <br /> GIS Coordinates:X ,Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> 0 SOIL BOR G# 0 OVER-BORE <br /> [WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS !I <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE__MULTIPLE CASINGS? YES 0 NO WELL CASING DIA:/9 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSSCTYPE OF CASING( STEEL AVC 0 OTHER: <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> a AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: Y[UggJs 0 No_(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONL7'C'�� <br /> 0 OTHER:_O OTHER APPROX.BORING DEPTH /0 = BOLTED TRAFFIC BOX or 0 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 O 1 ances, Rule and Re ulatio s, and all applicable/SayfOrnia State Laws. j <br /> 0C/ // tla�c([4 <br /> Signed x� rr � I itl�Company— Ky(�M ` � , k <br /> Print Name oc `GL t'v' Dated <br /> DEPARTMENT <br /> /•USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepte _—:d By Date Issued `-�� 171 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# IREC'DBY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> hment doc_ 9/27/00 <br /> C-57_ WCWAIVER_ C-57 Letter of Authorization to sign permit_Encroac <br /> = <br /> FILE COPY <br />