Laserfiche WebLink
Date Issued <br /> Final Inspection By <br /> 'ft* <br />ORIGINAL <br />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 />SITE <br />MITIGATION <br />UNIT IV <br />ow <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 />WELL Location,5U6 AC 'C I-C 0-e. Cross Street Ro bi n kW d O <br />ctity slzi c trfovk zip cicd 0 7 4=13,2_ ‘.71) _tut <br />PROPERTY Owner sto-u 81co, Address 5 .30F Pac . Ciz 4a citY 5-f a c frto r , zip? Vo 1 phone# /9) -. TI- <br />C-57 Contractor a W Di, t ilikt . Address /0-0 S' '4.-4 Sib/Pet cityni et) vi Zipq5-01Lic#3de*Y Phone# ci/6/ 77 7'- (IP.° <br />Consultant / Sub Contractor F4 V IPT.:. ni+4f0 I AteclAcress /07560./f Oriel( Wcerity Ph (ea tVictt 6 013VePhone#7/01, 3) - <br />GIS Coordinates: X , Township Range Section , Y <br />WORK TO BE PERFORMED: <br />70EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BOR G #0 OVER-BORE <br /> <br />0 WELL # ti) ---"---'—-. --..-0 " 3_, D 0 PRESSURE GROUT <br />*Other: / Grout Specifications: <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE /6 MULTIPLE CASINGS? U YES NO WELL CASING DIA: <br />CASING THICKNESS -3",h0d 114.) TYPE OF CASING: U STEEL kiPVC POTHER: <br />DEPTH OF GROUT SEAL ,1.5"I TREMIE TYPE TO BE USED: II AUGERS 0 HOSE <br />GROUT SEAL PUMPED: YeN 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: ifi-e 44-1,14-t 77:9 <br />APPROX. BORING DEPTH 5 -6 6 )(BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? 4/2) ( if YES, list specifications here): <br />*COMMENTS: <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 Oçtinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x Ce471 9 1 Srfitle/Company CR/17CA-6•1 S.,c7L <br />Date C / <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 5630(1) <br />WORK PLAN DATED: —o <br />TYPE OF WELL INSTALLATION TYPE <br />*MONITORING HOLLOW STEM <br />EXTRACTION h AIR HAMMER/DRIVEN <br />VAPOR UMUDROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />0 OTHER: 0 OTHER <br />Print Name B Q <br />Application Accepted By <br />Grout Inspection By I Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERM! ERVICE REQUES INVOICE <br />360 1 AAAA/ g7 3i1-/ Cpok 2.-I sR# 00 ))?Y <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit 9/27/00 <br />