Laserfiche WebLink
WELL, �RMIT APPLICATION FC . ,iA <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <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 />Assessor's <br />WELL Location i`�� Sc a th ( DG, o,�,c Cross Street Tv y A,t City -Zip PLarcel# <br />PROPERTY OwnerVC41 �� � C\ C ^+r�Ac y°S Address 1� �1 e7 [ f \(J 7 M City �ck-Ac',i ZiP 'ISAC t�hone# <br />C-57 Contractor �� f � S e\ S• +v- _ Address 15ll� I *c �'L I`cxI City I a, 4, n�L Zip ?y�S3Lic# b ' %Phone# 72S- 3 t3 <br />Consultant/ Sub Contractor il��lCncv��l Leo�rtv•rov'trkadress 937 Skc,cv City -iL0 ,,n Lic#(b8,C'<�ll Phone# <br />GIS Coordinates: X _ _ - , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />PEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) \ . <br />%SOIL BORING # P h /� 9 0 OVER -BORE <br />0 WELL # 0 PRESSURE GROUT 'r <br />'Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />�KPUSH POINT <br />jKZOIL BORING <br />0 HAND AUGER <br />0 OTHER: <br />0 OTHER <br />'COMMENTS: C \ T <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE T-\ MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: O <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 'Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: �0^} \6"^Crl <br />APPROX. BORING DEPTH FT [] BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here <br />. NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMIT5. <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 Or in nces, Rules and Regulations, and all applicable California State Laws. A /� <br />,("•' ,�� Title/Company SNL I��l�I`';°��/ �`'��a�J]�-/ �c�Cll✓r�pcY <br />Signed x _ <br />Print Name A'ni }o Itcn (L tti� � (r"� Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 3Y-17. 5'{ <br />WORK PLAN DATED: 2— Zdo 1 <br />Application Accepted By Date Issued J� /Z�i� Area Z �L <br />Grout Inspection By Date Final Inspection By Date <br />OMMENTS ! CONDrr10NS0 <br />C <br />I <br />AID# <br />TACCOUNTTINGNLY: <br />E INFO <br />AMOUNTREMITTED <br />CHECK# <br />REC'D BY <br />DATE PERMIT ! SE ST # <br />INVOICE <br />Sy <br />/5Z-)7 <br />�oZ6Z�a <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit y�clLvv <br />