Laserfiche WebLink
WELL ERMIT APPLICATION F <br />.M S� Ett3-tlY/'��. <br />SAN JOAQUIN COUNTY MIT10N <br />ENVIRONMENTAL HEALTH DEPARTMENT (5HD)' IV <br />304 E. Weber, Third Floor, Stockton, CA., 95202 PPS 12; 28 <br />(209) 468-3449 03 JUL 14 <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 Environmental Health Department. <br />( - 3 Assessor'32,33 r i 3�' L� <br />A <br />WELL Location `ls U)e-.lt `, S�nLd Cross Street 0 5 City 6L1 ZipParcel# <br />PROPERTY Owner Address $2y _City /Zjp�S-3 'hone# ,;?0'jTUw <br />C-57 Contractor A (5�• Address ity Zip %A1 `,Lic#_b A" -)a-7 )ne# <br />Consultant/ Sub Cntr Address VR w Cfiy Sl(1�Lic#_ Ire�� -hone#_ k) <br />GIS Coordinates: X Y Township Range <br />WORK TO BE PERFORMED: <br />NEW WELL/ BORING (CPOPROBE, HYDROPUNCH <br />OIL BORING # <br />WELL # <br />'Other: <br />COMMENTS <br />Section <br />HANC-AUGER, OTHER-) DESTRUCTION (choose type below) <br />0 OVER -BORE (� <br />� PRESSURE GROUT �} , <br />Grout Specifications: p� a 6\u_Iut <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />IJ MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE_ 1'/ MULTIPLE CASINGS? Q MULTI-LEVEL? tj WELL CASING CIA: <br />Q EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS (( TYPE OF CASING: O STEEL O FVC O OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS ,>1P HOSE <br />p AIR SPARGE / Ozone p PUSH POINT GROUT SEAL PUMPED: p Yes No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING O HAND AUGER GROUT SPECIFICATIONS: (jIC� <br />/ n THER: OTHER APPROX. BORING DEPTH O/ 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />'� CONDUCTOR CASING PROPOSED? /VA -/1( if YES, list specifications here): _ <br />'COMMENTS: L l�z��'s CGjGL �� %/1 / C'.lCi, C='�" T%'-� /-'11L.'!�'��`�'C� <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 and /Regulations, and all applicable California State Laws. / <br />Signed x ��/1G1�� C ��} Title/Company f \ b-) � � .1 l(i �-e X, i �T <br />Print Name_ �/ �I J _��� ` Date ^% <br />DEPARTMENT USE ONLY <br />,-,� <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: Oj <br />Application Accepted By Date Issued 7-17 -02 Area <br />Grout Inspection By Date]�[Z'-Z'/63 Final Inspection By ate 1� - w`r <br />Destruction Inspection By Date <br />COMMENTS / CONDIlTIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />RE 'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />�o� <br />�.B <br />/ - S'' <br />C-57 ✓ WC -WAIVER C-57 Letter of Authorization to sign permit oc 8/29/02 <br />