Laserfiche WebLink
ORIGINAL <br />WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br />C- 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />Ir (209) 468-3449 n [ <br />NON-REFUNDABLE PERMIT EXPIRES 7 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 />�\ ' Assessor's <br />NELL Location 2�0 N . `Mg:r SJC Cross Street err< City ����r.��-2Cs� Zip Parcel# <br />3ROPERTY Owner �� U Z� Addressv,% City, rJ�ZiP 53 3 b Phone# 1 <br />C-57 Contractor Address �S O ��'� `— City Zip <br />1.� Licila <br />Phone# S (3 S8t" <br />Consultant / Sub Contractor Q9c�wg', aQ l ec `�r Address �J\ S ` _ City i�� `J Lic# Phone# S2 L `� <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (C_ P_T j GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) [I DESTRUCTION (choose type below) <br />R SOIL BORING # `w < CPT 1 — 5 [I OVER -BORE <br />a WELL # [] PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS: SL 0.��C.caly. - n - y 3 \r� Ck) C f"12 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />Q MONITORING [I HOLLOW STEM DIA, OF BOREHOLE i� MULTIPLE CASINGS? [] YE [] NO WELL CASING DIA: <br />p EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS -- TYPE OF CASING: O STEEL p PVC [)OTHER:__ <br />VAPOR a MUD ROTARY DEPTH OF GROUT SEAL—OC)' TREMIE TYPE TO BE USED: [I AUGERS [] HOSE <br />p AI SPARGE6 PUSH POINT GROUT SEAL PUMPED: [] Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />®SOILBORIN 3 HAND AUGER. GROUT SPECIFICATIONS: G¢ <br />[) OTHER:_[] OTHER APPROX. BORING DEPTH p BOLTED TRAFFIC BOX or (]STOVEPIPE <br />CNDU\CT_OR(�CASING PROPOSED? (if YES, list specifications here): <br />*COMMENTS: �^� N F \ I — O 3 <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 1 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 State Laws. <br />Signed x l QTitle/Company°\ <br />Print Name J R 1 ��^ x- Date--!— I � — -3 <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: _ j/ -/ <br />Application Accepted <br />Grout Inspection By_ <br />Issued_ G (IJ Area <br />Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />C-57 Letter of Authorization to sign permit <br />"0<— Encroachment d, os,,�— <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />MITI SERVICE REQUEST INVOICE <br />j 501 <br />C-57^ WC -WAIVER_ <br />C-57 Letter of Authorization to sign permit <br />"0<— Encroachment d, os,,�— <br />9/27/00 <br />E8 EDV6 <br />6007-� HiAIJ <br />EEbE89b69Z 95:ET <br />T8©Z/8Z/Z0 <br />