Laserfiche WebLink
WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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 />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />b FF- C L � W fuu <br />�5 I <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 n 41 ` ° --A `~e Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />/ a 1—.11513,V <br />`15� ` / � t Oc a y Assessor's <br />NELL Location F� !( rocs Street it AI Q U zip Parcel# A/�0} <br />3ROPERTY Owner Cl tj 6k I. fo % Address N City l,A A rUy(Azip Phone# �" ,+� I, a <br />,'-57 Contractor ��I��e _DYt [6q(A Address VY 1.1f L�.�/ City n �A., ip��� �Lic#�i (L�Phone#Olw— nli' 1 <br />�t �I '�- IOo iA G�tO <br />:onsultant / Sub Contractor)sfl Lutz 1�1TGY� L►MLIt1l.Address I ✓tom 5� City 6✓/Lic# Phone# u u - i�(] <br />31S Coordinates: X 'U//} 'y AIM Township iV Range Al�h Section N4, <br />ORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, <br />r/ p SOIL BOR' GIf_ <br />61 WELL #_ <br />Other: �1 <br />30MMENTS:I 't Y CY <br />CrvtS�G� . i J �i9C12GtG 11�� �Y►� <br />TYPE OF WEL INSTALLATION TYPE <br />�'13�MONITORING HOLLOW STEM <br />] EXTRACTION 0 AIR HAMMER/DRIVEN <br />] VAPOR 0 MUD ROTARY <br />] AIR SPARGE 0 PUSH POINT <br />] SOIL BORING a HAND AUGER <br />J <br />OTHER:_0 OTHER <br />COMMENTS: 3 <br />S(Vlf ell <br />HAND -AUGER, 1 0 DESTRUCTION (choose type below) <br />OVER -BORE <br />All. 0 PRESSURE GROUT <br />G ecifications: <br />GUNS I KUG I1UN ArtGlrl',H1 wnO 7 II <br />DIA. OF BOREHOLE 4 I' MULTIPLE CASINGS? 0 YES ;�NO WELL CASING DIA: G <br />CASING THICKNESS �V(/ U TYPE OF CASING: p STEEL kPVC O OTHER: <br />DEPTH OF GROUT SEAL I TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: o Yes llo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: Wom <br />APPROX. BORING DEPTH x 2M 1 <br />CONDUCTOR CASING PROPOSED? <br />1A .. „, :nl 1,,,I <br />BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />( if YES, list specifications herg):_T� <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 />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />3ounty Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed <br />'rint <br />31TE MAP IN UNIT IV FILE, ADDRESS:. <br />NORK PLAN DATED: -6 <br />application Accepted By_ <br />3rout Inspection By <br />destruction Insoection By <br />`nUU1:MTC / r.nNnrTInNS• <br />Titi <br />DEPARTMENT USE ONLY <br />Date <br />3.7.0 .�e - <br />10-21 —02, — —Area O(O1?¢ <br />Inspection By <br />(5 - <br />Id d <br />ht", <br />ACCOUNTING ONLY: AID# rsr <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PE UEST # <br />INVOICE <br />.3501 <br />Utt 6'� `r <br />53 � <br />�L SR# CO..'" 59 <br />:-57 ✓ WC v -WAIVER_ C-57 Letter of Authorization to sign permit roachment d y/e-//UU <br />