Laserfiche WebLink
WELL PERMIT APPLICATION FORM SITE <br />MITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />i*VfR( yMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E."Weber, eber, 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 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 Couniy Public Health Services, Environmental Health Division. <br />Assessor's <br />,NELLLocational`-' N �� �Oc o� S�. Cross Street CityN Zip�c)1y4 Parcel# LLS - I3u - t -) <br />DROPERTY Owner �#-)Oh . er.� ` �`� Address \D ��mvIr Citys t �l�t Zip �S2° I Phone# 609 q-1 l 3i 1 <br />�S1CF, `lSby) Zz°gv�l <br />C-57 Contractory a�+`t �(u\\� _Address 0 City Zip Lic# Phone#ollb -1-1 1 1 <br />�nsultant Std 6entractor�Q Ji o -� ,c a lec}��t caAddress \y) \ �� S -t Lic# Phone#Z-'O 01 S LZ ui I l <br />GIS Coordinates: X 'Y , Township Range Section <br />WORK TO BE PERFORMED: <br />TAID# <br />[] NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) DESTRUCTION (choose type below) <br />9/27/00 <br />[I SOIL BORING # [] OVER -BORE <br />GROUT <br />" <br />11WELL # y �W \ a �.W �- ? W 1 a PRESSURE <br />1— <br />"Other: Grout Specifications: <br />DATE PERMIT 1 SE <br />COMMENTS: SAs>_ R - <br />7 <br />c, <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />I] MONITORING Ill HOLLOW STEM DIA, OF BOREHOLE MULTIPLE CASINGS? 11 YES ONO WELL CASING DIA: <br />A EXTRACTION p AIR HAMMER/DRIVEN CASINGTHICKNESS TYPE OF CASING: 0 STEEL D PVC []OTHER:__ <br />rye <br />VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: flAUGERS H HOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: a Yes [] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />[] SOIL BORING 0 HAND AUGER. GROUT SPECIFICATIONS: <br />.\ <br />[] OTHER, 0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or (] STOVE PIPE <br />SING PROPOSED? ( If YES, list specifications here): <br />\CONDUCTOI�C <br />*COMMENTS: VV�� <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS, <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FORALL 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 O inances, ui s a Regulations, and all applicable Californias� State Laws.. <br />Signed x ( TitlelCompany "v �Jf-,.y 'r) <br />Print Name Y.��d. �A �� Date S / ) 10/ J� <br />DEPARTMENT USE ON <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />I <br />ACCOUNTING ONLY: <br />TAID# <br />n oc <br />9/27/00 <br />i <br />PECODESFEE <br />INFO <br />AMOUNT REMITTED <br />CHECK # <br />R C'D <br />DATE PERMIT 1 SE <br />INVOICE <br />7 <br />c, <br />JZ 1 <br />C-57_ WC= WAIVER_ <br />C-57 Letter of Authoo sign perms <br />n oc <br />9/27/00 <br />�E ?Jb'd <br />cI00�8 Nl�I� E6hE89b66Z <br />95:ET <br />T86Z/9Z/Z0 <br />