Laserfiche WebLink
WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin Countyfor a permit to construct and/or install the vork described. This application is made in compliance vith San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards ofSan Joaquin County Environmental Health Department. <br />Assessor's /KM' 02... <br />WELLLocation 2115 W. Wck.....005-ion &tyre -}- Cross Street NIA City StockiDr) Zip i 52_o 3 Parcel# hiA <br />PROPERTY Owner Ont+ect Sitrale, Address 2_115 J. Wash' n5-1-vn Sf. City 51-0C.ki-DY) Zip c152.D3 Phone#209 - glob -LI1 <br />C-57 Contractor Fic...,(11 erwilohnnental Address — City&LSpiiii1jsZipi5Z5Z Lic#17F3E36 Phone# 2.0.9 -11 Z-- 3510 <br />Delta- 5c110 Rice Crer.K Picwil, f.ifscre_vi vq, <br />Consultant/Sub Cntr EnvironMental 0 ot‘Salt, Address Su,-I-e 100 City 1.4 ts.I 551 Lio Lic# Phone# lo5i - 697 - 5i 86 <br />GIS Coordinates: X N A , Township NA <br /> <br />Range Section <br /> <br />WORK TO BE PERFORMED: <br />ErNEW WELL / BORING ( CPT, 9EOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />gtaL BORING # C1P- 01 CiPIO <br />fl WELL # <br />El DESTRUCTION (choose type below) <br />El 0./ER-BORE <br />0 PRESSURE GOUT <br />*Other: Grout Specifications: <br />COMMENTS .--j-rn (ID) iecf- <br /> <br />SCI\ bortvnS <br /> <br />TYPE OF 1AELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 3' MULTIPLE CASINGS? 0 MULTI-LEVEL? [] 1/NELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 CIHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL b--1)71.4i TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />O AIR SPARGE / Ozone 'RASH POINT GROUT SEAL PUMPED: B )bs El No (NOTE: MAXIMUM FREE-F LL DEP-14 30') <br />BAIL BORING 0 HAND AUGER GROUT SPECIFICATICNS: tetAelt.A.0 IA"- 54 ri.k. .... <br />0 OTHER: a OTHER APPROX. BORING DEPTH I 5 i bq5 a BC1TED T FFIC BCD( or 0 S OVE PIPE <br />(2 A., a'e-ea , <br />( ..._, I CONDUCTOR CASING P OPOSED? ( if YES, I t specifications here): <br />*COMMENTS: _t W <br />f <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 ar P4t1atIons, and all applicable California State Laws. <br />pre:,\ e Ivlccryt.3e C <br />Signed x Title/Company Delta_ F VOYlvInalta CC VV-It-4-1-1111,11-S; <br />Print Name <br /> <br /> Date <br />DEPARTMENT USE ONLY <br /> <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date Issued Area 0 6Cf <br />Date Final Inspection B Date -e)." <br />Date <br />ACCOUNTING ONLY: AID# ,r-+6 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE/ PERMIT / SERVICE REQUEST # INVOICE <br />71° 1 / '51Pfr -5Z570 <br />C-57 V WC I -WAIVER 8/29/02 C-57 Letter of Authorization to sign permit Encroachment doc