Laserfiche WebLink
WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />402Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is madejin compliance with San Joaquin Caunty <br />Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. —f <br />,,// Assessor's <br />WELL Locationl�^S /N 6)4r'(PlOg!1'LD Cross Street i2Yi2c <br />�' / C / City ate;s Zip rL5 ; Parcel# <br />boOwner A( w—r (L {�* Address 2( 32 lt�! /}G lW, drjCity 5T&,a7a1( Zip�Phone# <br />C-57 Contractor' Address 11�� CityZip Lic# Phone# <br />Consultant / Sub ContractorQpYA, ai? �7"(t t[✓aEni/��'Adfdts `?31 Q.4t,0 A-) City 7 CLIC#&&,aLPhone��'4 <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) `DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE <br />_ L PRESSURE GROUT vim` <br />*Other:A„(y� -P&4 -T �/ (El t t 0 WELL <br /># # Grout Specifications: YOi-7LoWrD �YP� <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br />0 OTHER: p OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br />'COMMENTS: <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 thij application and that the work will be done in accordance with San Joaquin County Ordinances, <br />Rules aVZ- <br />g a ions d lira 1 ornia State Laws. <br />Signed x I Title/Company b Z>VAAt <br />Print Name amu(- (� (�b7SU^� Date _02-/-Z/a2_ <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By_ <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />Date <br />Inspection By <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATEII`` <br />T # <br />INVOICE <br />SR# <br />U- <br />C -57_ WC --WAIVER C-57 Letter of Authorization to sign per t Encroachment doc_ 25/02 <br />