Laserfiche WebLink
WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 ��M,Cb <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 />�yWP-ST 5ANNQ(' AAkmiz Avk. LO�; f �jSZyZ Assessor'/ <br />WELL Location L% V Cross Street CAit;+oL- Aui- City Zip Parcel# ;✓�✓ �p <br />PROPERTYOwnerMCfl fUAL,DS Address 450Z(;1c 94A—n <br />�5 y7ACF- City $TICK Toe-) Zip 952 0 7 Phone# 209 Y73 'C) t 3� <br />C40 M;KE TaFTT►� Lz> <br />C-57 Contractor N &I (ED Gtc Env. Address ��J% &14A ✓ RCA/) City SToCl�rcn Zip gSy� Lic#('80 Phone# tog YL 7 �0o <br />Consultant / Sub Contractor 14 F . <br />Address 5i 7 S/`> fFv / RaAA City 5rCX r'r'-i) Lic# 6ffo Z z 7 Phone# t e 9 <br />PE CODES <br />GIS Coordinates: X Y <br />Township Range Section <br />CHECK # <br />WORK TO BE PERFORMED- <br />ERFORMED:-ANEW <br />DATE PERMIT / SERVICE REQUEST # INVOICE <br />.3-501 <br />-A NEWWELL / BORING ( CPT, OPROB HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />OIL BORING # <br />P- 3 S H OVER -BORE <br />-� <br />]] WELL # <br />0 PRESSURE GROUT <br />C a <br />"Other: <br />Grout Specifications: _ <br />COMMENTS: SF ft wecl5-AP/Rp+.ep <br />woAK An CSG tk0 09 MAY Zoo t <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />N/79 <br />G MONITORING B HOLLOW STEM <br />DIA. OF BOREHOLE Z" MULTIPLE CASINGS? o YES -<NO WELL CASING DIA: <br />o EXTRACTION H AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: STEEL PVC <br />N /A� � 0 [] OTHER: <br />o VAPOR 0 MUD ROTARY <br />DEPTH OF GROUT SEALro1Al- Apr/+TREMIE TYPE TO BE USED: O AUGERSHOSE <br />B AIR SPARGE PUSH POINT <br />GROUT SEAL PUMPED: BY ls �o (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />•SOIL BORING 0 HAND AUGER <br />GROUT SPECIFICATIONS: 7 A R} AAA � <br />rrB OTHER:____o OTHER <br />APPROX. BORING DEPTH JAS R--F� BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specificatipns here): <br />'COMMENTS: 5E�— 4+4,q ..ISD <br />ACCESS A !itEZ M?44 Jz+wkEn h6r MCD oNA /oS <br />C OR/%r% <br />NOTE: OFFSITE BORINGS <br />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 <br />State Laws. <br />Signed x / Ciy�jV�+T-' ( Title/Company T 0 ��n� cO t51 <br />Print Name ' I N1 0 T14 y � , \ V � % �•��Q Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS:Gd�t- <br />i <br />WORK PLAN DATED: (iik S —2-0 2 - <br />Application <br />Application Accepted By Date Issued L 6 0 Z— p Area �� I <br />Grout Inspection By Date Final Inspection By z� Date <br />Destruction <br />"� 3 <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />cnrtt <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICE REQUEST # INVOICE <br />.3-501 <br />� <br />i <br />sR <br />C-57 V WC= WAIVER C-57 Letter of Authorization to sign permit Encroachmen oc 1/25/02 <br />