Laserfiche WebLink
WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />02� ENVIRONMENTAL HEALTH DIVISION (PHS -END) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />ons <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />?pplication 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 />HELL Location Z O �� s't Crass Street City ii\0\,ir-cy Zip 533^ Parcel# <br />"ROPERTYOwneC�—Y-OKfRr\tQ Address Z7 CityfN)c c -c\ ZipAS33lo Phone# Z35- l <br />C-57Contractor�l dr 0..\� - Address YO Q ib CityZipd�Sby�0\ Lic#1209°y Phone#j\P1-10 ' I <br />Consult nt/1&6t;6 ntractoro�,cvQ-Ta)"�h'UAddress 1i\31 ��`` S� Cit}Ir,,y�vjo�o Lic#— Phone#S2Z `��\`) <br />GIS Coordinates: X <br />Y <br />Township <br />WORK TO BE PERFORMED: <br />[] NEW WELL/BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />[] SOIL BORING # <br />I WELL # r--- '-J a <br />*Other: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />;1 MONITORING <br />HOLLOW STEM <br />I EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />IAUD ROTARY <br />[] AIR SPARGE <br />Q PUSH POINT <br />[] SOIL BORING 0 HAND AUGER. <br />[] OTHER: [] OTHcR <br />Grout Specificatio <br />Range Section <br />0 DESTRUCTION (choose type below) <br />[] OVER -BORE <br />a PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA, OF BOREHOLE MULTIPLE CASINGS? DYES ONO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: Q STEEL O PVC [)OTHER'— <br />DEPTH <br />]OTHERDEPTH OF GROUT SEAL TP.EMIE TYPE TO BE USED: [] AUGERS [] HOSE <br />GROUT SEAL PUMPED: 0 Yes [] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING (P(ROPOSED? (if YES, list specifications here): <br />*COMMENTS: S ��G.`�241 `�'�c" <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INISPECTIONS. <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 State Laws. / <br />Signed x ` TitlelCompan ��` `\ t ri� Jr V A -J <br />Print Name F—�` Y` o "`�j \1rr,1� v -- Date <br />DEPAARTME-N/T USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDF.ESS: r� N' k� —' , <br />WORK PLAN DATED: <br />Application Accepted By ate Issued / <br />Grout Inspection By Date U 0 Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS 1 CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED CHECK # <br />REC'D BY DATE <br />t /SERVICE REQUEST <br />INVOIC <br />C-57__WC-WAIVER_ C-57 Letter of Authorization to sign r)errnit4r--Ea hmen 9/27/00 <br />Ee 39t8 c�007�-+ Hi.�r-� EEbEB9bE0Z 9S:CT Teel/9Z/Z0 <br />