Laserfiche WebLink
, Township GIS Coordinates: X Range Section <br />Date Final Inspection By <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign perFtt tncroacrlrrlenT <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 />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 />Assessor's <br />WELL Location 17 .20C .19 ;4'.")-7L- Cross Street 44 • YPP---);b..- City "Yr4. Zip 7 533 7-Parcel# 2-00 Ha if <br />PROPERTY Owner <br />C-57 Contractor <br />Consultant / Sub Contractor <br />1.1fr74 C Address 6A5' Pc r+AI City /44,-)17.".4.--, zip 75337Phone# -ot ii cv <br />(y.17 Address H--- IC) Cityrkv--/-i4..... Zip "(-5-5) Lic# <br />Lt." Address 20e 1-)- P ,rfo-cic.), <br />2,z -3/3 -Sired Phone# <br />City Pow, Lic# Phone# <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HB,ID-AUGER, OTHER') <br />g-SOIL BORING # <br /> <br />WELL # <br />"Other: <br />COMMENTS: <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />U PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE <br />fl MONITORING a HOLLOW STEM <br />EXTRACTION AIR HAMMER/DRIVEN <br />a VAPOR flMUD ROTARY <br />p AIR SPARGE PUSH POINT <br />/gOIL BORING fl HAND AUGER <br />OTHER: 1:1 OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 7" MULTIPLE CASINGS? DYES 0/NO WELL CASING DIA: /2-1,g' <br />CASING THICKNESS itik TYPE OF CASING: p STEEL a PVC 0 OTHER: <br />DEPTH OF GROUT SEALT;dovi TREMIE TYPE TO BE USED: El AUGERS p HOSE <br />GROUT SEAL PUMPED: U Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />4. GROUT SPECIFICATIONS: 1L- <br />APPROX. <br />red <br />o BOLTED TRAFFIC BOX or STOVE PIPE BORING DEPTH /5k-f-'- <br />CONDUCTOR CASING PROPOSED? A4- (if YES, list specifications here): <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 Ordinances, R es and lations, and all applicable California State Laws. <br />Title/Compan Signed x <br />DEPARTMENT USE ONLY <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: 0_0-7 <br />WORK PLAN DATED: L.),_}, <br />Application Accepted By <br />Grout Inspection By Date <br />Destruction Inspection By Date <br />ACCOUNTING ONLY: AID# FAC# •• - <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT REQUEST # INVOICE <br />'-go-4) 1 :-..t-t ,0.1,4e r 3 - , J _ _ A P-1-7 inn t 1,--- <br />SITE <br />MITIGATION <br />UNIT IV <br />Grout Specifications: <br />c„..c. re•-1. <br />Date Issued Z.( Area