Laserfiche WebLink
WELL PERMIT APPLICATION FuRM SITE <br />MITIGATION <br />`.J J SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />1'- ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />CC (2 4 200 _ 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 458-3449 <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 Sari <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin aunty Public Health Services, Environmental Health Division. <br />Assessors <br />WErJLavation kcv; Cross Street ftu✓r;51�0v reo Ci tyS1cx-� 2 <br />G_I- <br />T <br />c �� ) c h Zip � 'Phon �>q}�,'�7"6e) <br />PROPERTY OwnerCite; il.1 > Address I ' Q City <br />r C o0. S Coy p r , d _ -_ 1" � <br />C-57 Contractor <br />Consultant/ Sub Contractor N ��, ✓? C��'� Address <br />GIS Coordinates: X , Y Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') <br />0 SOIL BORING # <br />p WELL # <br />'Other: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />0 HOLLOW STEM <br />0 EXT-RAC71ON <br />0 AIR HAMMER/DRIVEN <br />[] VAPOR <br />0 MUD ROTARY <br />AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />I7 HAND AUGER <br />0 OTHER:__- <br />OTHER. <br />COMMENTS: <br />Grout Specifications: <br />­*6ESTRUCTION (choose type below) <br />0 OVER -SORE <br />RESSURE GROUT <br />CO <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE_ MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA:____ <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HGSE <br />GROUT SEAL PUMPED: 11 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH __ 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE 91 <br />CONDUCTOR CASING PROPOSED? _ _ (if YES, list specifications here): ____. <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PEKMI I s. <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, Rules and�.#iegulations, and all applicable California State Laws. <br />Signed x. <br />Print <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: )zc'I <br />Application Accepted By�� ✓ Date issued Area <br />Grout Inspection By C ate °� Z Final Inspection By Date_ <br />r 117 0,C <br />Destruction inspection By 1 to <br />COMMENTS/CON <br />ACCOUNTING ONLY: AID# G 11 <br />PE CODES <br />FEE INFO AMOU NT REMITTEDREC-D <br />&CHECK# <br />BY <br />DATE PERMIT/f SERVICE REQUEST0� <br />if� <br />C-57 WC -WAIVER C-57 Letter of Author4z4lorl t4 ign permlT cncrouLMIM-111 -__ - -• -• • - - <br />