Laserfiche WebLink
WELL PERMIT APPLICATION FAM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />10 04 6 at 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />2 <br />(09) 468-3449 <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 Environmental Health Department. <br />/>1� ^� o� /J D G, / 2 (�, Assessor's <br />WELL Location x`11 /� ` o J �j� Cross Street 6 �t / t G/���(, Zip I D33 Parcel# a c1 <br />PROPERTY Owner Oma- � I f Address) / 7S �e/Iy� Cit4S " "' -'"t Zip hone# 2� 1 ! 64 " F(� �Y <br />NA2 3233 �^ s`'` tv i4 p�s�`��t; # ` P # /� &-2 72�� <br />C-57 ContractorW� /]nom Address [ Cif) Q L Zi c hone ,// / <br />Consultant / Sub Contractor t �L Address �J� s/lG'� rl ` City��- Lic# Phone#201` 67 / �b <br />GIS Coordinates: X <br />Y <br />Township Range Section <br />FEE INFO <br />W RK TO BE PERFORMED: <br />CHECK # <br />NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") [] DESTRUCTION (choose type below) <br />` <br />0 SOIL BORING # <br />[] OVER -BORE <br />\) <br />�'�S I[j WELL # <br />0 PRESSURE GROUT <br />` <br />"Other: �l <br />{ �4> h <br />Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECI •ICATIONS <br />I nG� <br />[]' MONITORING <br />[f HOLLOW STEM <br />DIA. OF BOREHOLE �G ULTIPLE CASINGS? YES 0 NO WELL CASING DIA:-,2-T <br />EXTRACTION <br />[] AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: [] STEEL [] PVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p'AUGERS [] HOSE <br />0 AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: 0 Yesff No (NOTE: , MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS: lam <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 3 Q <br />C NDUCTOR CASING P/R POSED? <br />� <br />'COMMENTS: l-5� i Y11 IVIQ e ` S <br />.TED TRAFFIC BOX or 0 STOVE PIPE <br />( if YES, list specifications here): <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 <br />,S�ttaate Laws. <br />Signed x %_ {�y� IiC`�G�_ `� Title/Company <br />Print Name l� V t cQw-- Ie- Date <br />/}DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE. ADDRESS: "/ d5 , l k M", 7 <br />WORK PLAN DATED: 3 / //I <br />Application Accepted <br />Grout Inspection By_ <br />' 1 C ys <br />Date Issued //��� �L�` `� aa Area <br />_Date 11 Final Inspection ByDate <br />Destruction Inspection By LDate <br />COMMENTS / CONDITIONS: <br />C <br />0 <br />ACCOUNTING ONLY: <br />AID# cnr4t <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PE UEST # <br />INVOICE <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign perms Encroachment &6 1/25/02 <br />