Laserfiche WebLink
WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />C- F77 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />6N <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 />/ Assessor's / <br />WELL Location 3'Tr`-f O 6QSf1 (( Q�t Cross Street 0 n- - eCity / Zip <br />,� �} 2 Parcel#;j�-� <br />PROPERTY Owner Ra KCAI � Ad e, r2ad Address'�f $ Pon((. 1d i2 7a City tufa ,Vl (Ap - 60 52Phone#�V 5j c <br />C-57 Contractor V - K Address C(S{i (t /e (Lr(Cit���Cfa� <br />ZipCf Lic#'{Phone# - <br />Consultant / Sub Cntr 1 tit q ✓D-% ess City ( � <br />LicQ&#53oPhone# &6)g31-2,110 <br />PK�I�w, S fi <br />GIS Coordinates: X , Y ,Town hip �Wvtinge �-lE Section <br />WORK TO BE PERFORMED: �� <br />NEW WELL / BORING ( PT GEOPROBE, HYDROPUNCI-i HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />4 OIL BORING # `� 0 OVER -BORE <br />0 WELL # 0 PRESSURE GROUT <br />"Other: Z CPi rlt�tGrS ?Lr f GSW 4d.kfo P t4Grout Specifications: <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �I 'LL <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE — a," MULTIPLE CASINGS ULTI-LE EL?*HELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASIN - /'"''" <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE / Ozone 0 PUSH POINT <br />SOIL BORING 0 HAND AUGER <br />0 OTHER: OTHER C P n <br />'COMMENTS: <br />DEPTH OF GROUT SEALTREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE Cn <br />GROUT SEAL PUMPED: 0 Yes 0No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: V4A t CQ•(M !:�! / % 5 ►M' <br />APPROX. BORING DEPTHnrr n�_P4^^ <br />CONDUCTOR CASING PROPOSED? K if YES, list specifications here): <br />G(ed ►rvti1�, r��(s 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 Orli es, Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company -(7• Z�50 r7 C7�'r <br />Print Name �� �N��1"7 "d Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection <br />Destruction Inso <br />COMMENTS / CONDITIONS: <br />6 -1 3'0-J? <br />Date <br />Date <br />ate Issue <br />Final Inspection By <br />a <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE RIGHT / SERVI INVOICE <br />S R#00 <br />C-57 V WCC/ -WAIVER_ C-57 Letter of Authorization to sign permit ncroachment doc 8/29/02 <br />