Laserfiche WebLink
WELL PERMIT APPLICATION FORM <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 />ORI L <br />SITE <br />MITIGATION <br />UNIT IV <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 />n 0 I /1 / Assessor's <br />WELL Location_)) S- 30 1�.� nF-1< ,+ M' L 1'4 Cross Street A 4,p Ir'�tn. 1<A City Zip S'� I Parcel# � - 5 �i -i� <br />PROPERTY OwnerU*-5+PG / rA r' J� � s Address/ q goo �it�• rytc� 4 ►�+_ 4TCity I-od, Zip'?5;12 Phone# <br />C-57 Contractorww 4 W A rd17r 1IL —Address P.O. P o- 336 city2,oO Zip 7c+ yS 7/ Lic# -1 1007 Phone# -7 07 - 57 y -x%340 <br />Consultant / Sub ContractorATC 45so!r= .ZncAddress 1//7 L,on,A itydec d Lic# Phone#.ZOy•-S X21 <br />GIS Coordinates: X Y Township 2 N Range ✓ Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type belcyy) ^, <br />0 SOIL BORING # 0 OVER -BORE V <br />Qj..WELL # f�1 l..l � � PRESSURE GROUT <br />'Othee: Grout Specifications: <br />COMMENTS: - <br />TYPE OF WELL <br />INSTALLATION TYPE <br />MONITORING <br />$ HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER: <br />' .OTHER - <br />'COMMENTS: <br />CONSTRUCTION SPECIFICATIONS pn <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES )I NO WELL CASING DIA: 2" <br />CASING THICKNESS SCI.. '10 TYPE OF CASING: 0 STEEL X PVC 0 OTHER: <br />DEPTH OF GROUT SEAL I � TREMIE TYPE TO BE USED: g AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') (L`l <br />GROUT SPECIFICATIONS: /V 3/ <br />APPROX. BORING DEPTH 3 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? NG ( if YES, list specifications here): <br />NnTF- nFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL PtUUIKtU INZ)Vr-1, i iUrva. <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 ��G/11.�to +� C • Title/Company -Bran,--In I I,A 1'- r7 / c- >�SU L <br />Print Name Date ✓� A-) - <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 0 <br />WORK PLAN DATED: -/ -00 S•OD i <br />Application Accepted E <br />Grout Inspection By_ <br />Destruction Inspection <br />r^amsmC►ITe t f rikinrrinmQ <br />Date I <br />- <br />i <br />/_ EMO, - <br />Final Inspection By <br />[,� <br />(� O�.�erea 0%i� T <br />—0 2- <br />ACCOUNTING ONLY: AID# <br />FPIIMITISFR�ICE <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE REQUEST # INVOICE <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ 9/27/00 <br />