Laserfiche WebLink
C) Yr4 <br /> WELL-PERMIT APPLICATION FvRM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESH E� N <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) 1) <br /> _ 304 E. Weber, Third Floor, Stockton, CA., 95202 .JAN 2 200 <br /> (209) 468-3449 <br /> ENVIRONMENT HEALTH <br /> NON-REFUNDA13LE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 Public Health Services,Environmental Health Division. <br /> Assessor <br /> VYEiI.i ccation _Cross Street Lor-5km r City u C Zip, 6 Parcel# - <br /> PROPERTY awner_/i't a� QV (6h4c S _ _Address a ��5Q '�1� _ City t Zip�SPhonell��d y�� <br /> C-57Contractor0 Ae,l Dr1010- QgQ_Addrress U 5,U4 Ay City�crGrZip`7 L6 uc# b�Phon �__95 ' 59 <br /> Aro <br /> Consultant)Sub Contractor �i .ateyE'Gf [amu-ss!n 10 Address..'i33_7 56C'd .M� _CityS Lid#6gOja7Phan -2 �f <br /> GIS Coordinates:X .Y Township Range Section <br /> WORK TO BE PERFORMED: . <br /> -g pdE+N WELL/BORING(CPT.GEOPRCBE,HYOROPUNCH,HAND-AUGER,OTHEIr) �DESTRUCTION.(choose type below) <br /> `1 j]SOIL BORING# Q OVER-BORE . <br /> "ELL# - Q PRESSURE GROUP <br /> "Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS t <br /> MONITORING OLLOW STEM DIA.OF BOREHOLE'MULTiPI E CASINGS?U YES-,'%40 WELL CASING DIA-, <br /> p EXTRACTION fl AIR HAMMERIDRIVEN CASING THICKNESS 7rCL �d TYPE OF CASING: 1]STEEL VVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL7-1---, v <br /> TREMIE TYPE TO BE USED: GAUGERS Q HOSE <br /> Q AIR SPARGE [I PUSH POINT GROUT SEAL.PUMPED: [Y Yes Doo (NOTE: MAXIMUM FREE-PALL,DEPTH IS 30')' <br /> []SOIL BORING 1]HAND AUGER GROUT SPECIFICATIONS: IvUte[ o <br /> OTHER: 11 OTHER APPROX BORING DEPTH O f]BOLTED TRAF,=1C BOX ar ©STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here}: __-- <br /> 'COMMEN'T'S: <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, Rules and eguiat'lons,and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print NameIc <br /> -Date 12&� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNrr IV FILE,ADDRESS: 4 e,4 <br /> WORK PLAN DATED: A / o" <br /> Application Accepted By Date Issued Z'7 [i_Am, <br /> Grout Inspection By Date Final Inspection By Dale <br /> Destruction Inspection By . Date <br /> COMMEN'T'S/CONDITIONS- <br /> ACCOUNTING=NLr=_ A1 <br /> PE CODES FEE INFO AMOUNT REMn TED CHECK# REC' BY OATS PERMIT 1 SERVICE REQUEST#. INVOICE <br /> a s-o l 0 0 SIR# OCA J C7 <br /> C-57 WC -WA1VEIZ C-57 Letter of Authori do to 9rt Encroachment doc .9/27/00 <br />