Laserfiche WebLink
WELL PERMIT APPLICATION FORM SITE <br />MITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />ENVIRONMENTAL HEALTH DIVISION (PHS-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 />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 />C n < ,, Assessor's <br />WELL Location 17 CI�� L •/nom G. n (,� Cross Street Q O �` rcity ✓T—C%-��Zip Parcel# <br />PROPERTY Owner_ ) e AC' 1� Address P o 13 0x b City-+�UG�C f tti zip�]J�Phone# <br />C-57 Contractor (.v r L 2 CZrd dress �0 7334 City 0 1 Zip 1�`r ] Lic# 7l aa79 Phone# 7G - 1Z <br />Consultant / Sub Contractor y+ i ac iG Address % LQ►a P 14W. Cityhiiok5ttLLic# Phone# <br />GIS Coordinates: <br />WORK TO BE PERFORMED: <br />&NEW WELL / BORING (CP <br />*Other: <br />(`r)hAl\AFNTS <br />Y <br />Township <br />Range <br />Section <br />T, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />[] SOIL BORING # 0 OVER -BORE <br />qY-nVELL # =Z,) / T�v T. � `f =w S� 0 PRESSURE GROUT <br />y TGrout Specifications: /V,2 e { r 47 #.4-j <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />:.{}iit7LLOW STEM <br />0 EXTRACTION <br />[] AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />LG -OTHER: C3 Zn,1tc�;rx0 OTHER <br />�h <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE` _ MULTIPLE CASINGS? g -YES 0 NO WELL CASING DIA: <br />CASING THICKNESSSTYPE OF CASING: 0 STEEL 43 -PVC 0 OTHER: <br />DEPTH OF GROUT SEAL 63 TREMIE TYPE TO BE USED: 41-ACIGERS 0 HOSE <br />GROUT SEAL PUMPED: ,fixes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: 1,j A z I' C�.,,,A,,,, Y7-- .- <br />APPROX. BORING DEPTH / / G � $-BeLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? c, ( if YES, list specifications here): <br />NOTF- OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL MtU1UIMtu inarr-t-,1 ivrvo. <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 Ind Regulations, and all applicable California State Laws. <br />UUTitle/Company <br />Signed x AA <br />��...r Date 1, Z <br />Print Name <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: �U <br />WORK PLAN DATED: <br />Application Accepted By C.v. Date Issued t 2h O Area <br />Grout Inspection By_� C'cv1 Date Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / C <br />Arr,ni iNTiNr. ONLY: I Ain# <br />� r (lN'). i,�01_3 <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # INVOICE <br />3 sol�j.oa <br />�� S <br />Lti o <br />3b`}jn� Inn <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment ooc y(c/(vv <br />