Laserfiche WebLink
WELL PERMIT APPLICATION FORM SITE <br />Ing �`� it ` �'� - MITIGATION <br />"��✓' SAN JOAQUIN COUNTY <br />UNIT IV <br />0117-0 2 E 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />ENVIIRDNMENT HEALI rl (209) 468-3449 <br />PERMIT/SERVICES <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 ! <br />nc with �O <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department.Assessors 137-2Z001 <br />.}20 �, ��dIJ150/V ST Cross Street-�IVL441TSTCity STDG -/-704 Zipys2-lJ3 Parcel# � �S ROS <br />WELL Location <br />La RAE I S <br />1.,4s �LG� �/_ �L DAA a CI� �OGfG7 Zip -70!t- hone# 73-7 O� <br />PROPERTY OwnerGl! of=s txacraAl Address ty <br />��/ c������,,�,�D p � Sin- 34 <br />lrj(01J J�1.11"`� Address �J • ST CitY�*+""_LIp I��$Lic# �38Phone# S <br />C-57 Contractor sr� 13ov (� <br />'t70NEL7YON •F-"DieI.GEW(eiM►l� C�oN(E�5rdity SF Lic#�l'hone# -955 <br />Consultant /Sub Contractor r+��^"�O/� Address555 KION i D <br />d <br />GIS Coordinates: X <br />Y , Township Range Section <br />WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br />0 NEW WELL / BORING ( CPT, C�EOPROBE, HYD PUNCH, HAND -AUGER, OTHER-) 0 OVER -BORE -s <br />/SOIL BORING # 0 PRESSURE GROUT C <br />DWELL # <br />Grout Specifications: <br />'Other: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMERIDRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />OPUSH POINT <br />SOIL BORING <br />0 HAND AUGER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE -:_ " MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL (DTP 11 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE J <br />GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />X BORING DEPTH <br />OTHER APPRO 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />0 OTHER:—D <br />LD (5 Di P�> CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br />'COMMENTS: 0SoI1[­SRI IS 65 TO N 1 1pq S <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 Ordin nc s, les d Regulations, and all applicable California State Laws. - <br />Signed x Title/Company SP. L7PJ(y���a <br />/ / /b Z 313 <br />-n �__ , f � �_ . _ 7%l� � 1i�b(� Date <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />DEPARTMENT USE ONLY <br />WORK PLAN DATED: <br />Date Issued F � � O Area <br />Application Accepted By Date 1 1 <br />Grout Inspection By Date Final Inspection By J Ir�61ti( <br />C-57 <br />WC -WAIVER <br />