Laserfiche WebLink
S • <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 /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <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 -5,317 "(41-(771 /14 /7e 77 Cross Street /1-154/04/6C. City Zip Zip Parcel# e587 - 0Y6 -46 <br />PROPERTY Owner 417-.1) 4-17VJ2 Address 375-0 /7C-7' 71 City ic,e--(.47-0/74 Zip ....570 / Phone# <br />oe-frf-e64, <br />C-57 Contractor/4'22. Address )632- 04/e-e- 2.. City ap",arri-f-- Zip1.57YZ Lic#745-7/0 Phone# <br />Consultant/Sub Contractor ,-.0-0 00‘- -.4."1-0e447741,/kINFess 70/2 4/) City c"•-•1410•4f-Lic# Phone# -2Y-ova 0 <br />400 <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />ANEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />[] SOIL BORING # <br />X_WELL # Oeve-- <br />*Other: <br />COMMENTS: <br />-524 <br />Grout Specifications. CS-1 <br />[] DESTRUCTION (choose type below) <br />[] OVER-BORE <br />[] PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE r MULTIPLE CASINGS? [] YES (NO WELL CASING DIA: 19.2." <br />CASING THICKNESS $644 V° TYPE OF CASING: [] STEEL APVC [I OTHER: <br />DEPTH OF GROUT SEAL I/SI TREMIE TYPE TO BE USED: )(AUGERS [] HOSE <br />GROUT SEAL PUMPED: A'es [] No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: #4/0-47 <br />APPROX. BORING DEPTH 70 XBOLTED TRAFFIC BOX or B STOVE PIPE <br />CONDUCTOR CASING PROPOSED? /1/0 ( if YES, list specifications here): <br />111.04//24* 7-27 70 M tk) <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />TYPE OF WELL INSTALLATION TYPE <br />XkEAONITORING )(HOLLOW STEM <br />1:1 XTRACTION [] AIR HAMMER/DRIVEN <br />[]VAPOR [] MUD ROTARY <br />o AIR SPARGE [] PUSH POINT <br />0 SOIL BORING [] HAND AUGER <br />I] OTHER: 0 OTHER <br />*COMMENTS: <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 ules nd Regulations, and all applicable California State Laws. <br />Signed x ----- Title/Company 5-,11 <br />Print Name /..--le1/7— riel€------.5 Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: (s, I Q I\) • <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS. <br /> <br />Date Issued <br />Date [247/0 -2— Final Inspection By <br />Date <br /> <br />Area <br /> Date-7717T <br /> <br />c <br /> <br />ACCOUNTING ONLY: AID# -SrRoo3e7,;? • <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />3 5-0 ( VI - C? 0 .5-2. 62 % 5s (A.( 6[24P2- SR* 30 1 7_ <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br /> <br />Encroachment doc <br /> <br />9/27/00 <br />