Laserfiche WebLink
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 <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 v ork described This application is made in compliance with San <br /> Joaqum County Development Title Chapter 9 1115 3 and the Standards of San Joaquin County Publsc Health Services Environmental Health Division <br /> Assessor's _ 14-- <br /> �� '{L tq, u��t,/E•Cross Street u/ �d,>° City -�A'^1erACAzjp 3 7 Parcel# <br /> WELL Location 't�if �K <br /> PROPERTYOwner GAJZI, J(Z'("IJ Address C,ty Zip Phone# <br /> ` <br /> el9 S- 313 -sY0 v <br /> A/JxyLZtp9l <br /> C-57 Contractor Address Uie f3 Lac# Phone" <br /> Consultant!Sub Contractor .t {hr( <br /> �, ,tet/ Address 21W W, vi �6 kI City Vcsr+v,l fc L,cK Phone# 9LS- R?0 - 9.391 <br /> GlS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED p DESTRUCTION(choose type below) <br /> NEW WELL!BORING(CPT GEOPROBE HYDROPUNCH�HAND-AUGER OTHER ) 0 OVER-BORE <br /> 0 SOIL BORING#_ PRESSURE GROUT <br /> WELL# <br /> 0•Other Grout Specifications <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE��MULTIPLE CASINGS?0 YES !3 NO WELL CASING DIA <br /> II EXTRACTION 0 AIR HAMMER]DRIVEN CASING THICKNESS�-TYPE OF CASING [I STEEL 0 PVC 0 OTHER <br /> []VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL CK TREMIE TYPE TO BE USED AUGERS []HOSE <br /> SPARGE 0 PUSH POINT GROUT SEAL PUMPED $Yes Q No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> VIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ; &""J <br /> 0 OTHER 0 OTHER APPROX. BORING DEPTH 140 D BOLTED TRAFFIC BOX or l3 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED2,vA (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 /> hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordinances s and R ulatlons, and all applicable Calrforrila State Laws <br /> Signed x <br /> Title/Company f-f <br /> Date— <br /> PnntName r- <br /> :91.1 z���f — <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS a�-121 <br /> WORK PLAN DATED <br /> v �' Tr�✓ Dale Issued J c1 <br /> Area <br /> Application Accepted By a Date Final inspection By Date <br /> Grout Inspection <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS <br /> CCOUNTiNG ONLY A1D# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMfT!SERVICE REQUEST# INVOICE <br /> 35o 1 16 y� IC 01 1 5Uq \ <br /> C-57 WC -WAIVER C-57 Letter of Author'lzatlon to sign permit Encroachment doc 4/27/00 <br />