Laserfiche WebLink
U rr '':. = ;1'y�,+pa; WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> "!'t 'V SAN JOAQUIN COUNTY <br /> �. uUNIT 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 fora permit to construct and/or install the work described. This application Is made in compliance with San <br /> Joaquin County Development Tille,Chapter 9-1115.3 and the Standards of San Joaquin County ErrAronmentaf Health Department. <br /> tO�.� Assessors <br /> ' WELL Location, Z02 ar 99 Goss Street trey W A&owCity <br /> PROPERTYOwner IIJW Addresaj29/��City <br /> C-57 Contractor 1451 Addrea; / 6s CitA4 *//j pg/ 7xuott -wh, <br /> ' consultant l Sub Contractor,.n� 4p 6 ErodAddress`���7 �C 91�^yrLYx.,City�NYiJ77Lic# Phone# �i`s9Oa,_Q <br /> GIs Coordinates:X ,y.Township Range Section <br /> ' WO K TO SE P FORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION(choose type below) <br /> Ar501L BORING# 2 0 OVERBORE <br /> WELL# 0 PRESSURE GROUT <br /> t <br /> Other: - Grout SpeciFlcations: <br /> COMMENTS: 7-4/0 p P��J✓a 6e /gar K S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2 �• MULTIPLE CASINGS?Q YES Ij NO WELL CASING DIA:_ <br /> U EXTRACTION 0 AIR HAMMEWDRIVEN CASING THICKNESS_, 1A TYPE OF CASING: a STEEL 0 PVC a OTHER- <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_? -SU✓- _TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> ' 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: e,14-55 6. 44W&7 <br /> 0 OTHER: Tt OTHER APPROX BORING DEPTH_ 4 0 BOLTED TRAFFIC SOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? 1J,4 (if YFS,listspecifications here): <br /> -COMMENTS- Pe- � G��Or G/a p'�' '0/(P, <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 Ordinances,RuI s and Regulatio ,and all applicable California State Laws. <br /> Signed x /"' / TillelCompany 610 n? &y7& 7 / <br /> ' Print Name Ji/P /++ G 1'�l Date <br /> DEPARTMENT USE ONLY. <br /> SITE MAP IN UNIT IV FILE,ADDRESS L I S. r 12th 7 7 ! <br /> ' WORK PLAN DATED: 17a <br /> Application Accepted By t�N"'^'`1� Dale Issued f f n I Am.D-L-- <br /> ' Grout Inspection By Date Firtal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS(CONDITIONS: <br /> ACCOUNTING ONLY: AID# oerx <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SD + l - i `i �I SRit (^L35 <br /> C-57— WC_WAIVER_ C-57 Letter of Authorization to Sign permit_Encroachment doc_ - I/Z5/02 <br />