Laserfiche WebLink
PAGM�vED WELL PERMIT APPLICATION FORM <br />RE <br />MAR 1200 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />�o�Nn ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />SAN JOAO tN <br />Np4EN�Pt T 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />ENVtFD�1 AR(MEN (209) 468-3449 <br />HEP�SN <br />SITE <br />MITIGATION <br />UNIT IV <br />ORIGINAL <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 San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />L / Assessor's <br />C �I. (/� ►s t►Nv L*t- Cross Street 1z / City Zip y'ST� Parcel# 011 -320-W <br />WELL Location <br />Cdt1L°Cu, �lab„tLl,. Address 3 TC -6 14',(”cv ff wi w`ICity �N Zip �'O�hone# .'C'A <br />PROPERTY Owner •i <br />C-57 Contractor WDC-- Address /S �lt�' ` !c� Cr33 Cit �" ),Icz Zip 5 zr�Lic# � �� hone -Y (6Z -nom <br />Consultant / Sub Contractor 7Ci C t� Zi.�- 4;1:1-) ;7Address 717 E, I f_. l� City / . ��c� Phone#' y e ;t Y(C <br />GIS Coordinates: X <br />Y ,(,W , Township .VW Range <br />AAV Section AA4 <br />WORK TO BE PERFORMED: <br />t}6NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />AMOUNT REMITTED <br />CHECK # <br />SOIL BORING # <br />0 OVER -BORE <br />INVOICE <br />PE CODES <br />WELL # <br />✓tJ S -(C 0 PRESSURE GROUT <br />89.00 <br />'Other: <br />COMMENTS' <br />Grout Specifications: _ <br />(L- i 44"w.J OS-- 12 S1-+ c <br />Qr, <br />2r-,',,:- '412r <br />O <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS e� <br />WELL CASING DIA: <br />0 MONITORING <br />/,g HOLLOW STEM <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES a NO <br />E <br />y� <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS SC qO TYPE OF CASING: 0 STEEL APVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL 2 TREMIE TYPE TO BE USED: 0 AUGERS LS HOSE <br />4AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: rQ Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS: (f:G i�I A- <br />0 OTHER: <br />OTHER <br />APPROX. BORING DEPTH 3c: ja BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />y� <br />j <br />_O <br />CONDUCTOR CASING PROPOSED? tiAL ( if YES, listspecifications here)//: <br />'COMMENTS: <br />'i 7 <br />t�3t- <br />�� �� LlG/'. ) i1-� LLr <br />r i <br />NOTE: OFF ITE 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, Rules and&Regulations, and all applicable California State Laws. <br />Signed <br />Print N <br />Title/Company 'PI -4) G 4 SCt-C, /-75 <br />Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 3202 V1►eS+PCI yn rn er Lane- <br />WORK <br />aneWORK PLAN DATED: Se m.b1 S - 2- d <br />Application Accepted By Y -.'&L r Date Issued M a re,lt 12 2 0 04 Area 4 S <br />Grout Inspection By . r tc r , �, t Y1Z C �;� }�c6'� Date 3 3 Final Inspection By V etc r'; i j�/cCh - i� e� Date qlz1_611171_--------------- <br />Destruction Inspection By Date <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_ Encronchmem aoc_ 7/ C_ I I <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICE REQUES <br />INVOICE <br />PE CODES <br />FEE INFO <br />35-0 I <br />89.00 <br />r89.00 <br />D 20 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_ Encronchmem aoc_ 7/ C_ I I <br />