Laserfiche WebLink
WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> ON-REFUNDABLE PERMIT EXPIRES 1 YEAR F OM DATE ISSUED <br /> Application is her by 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 vainnmant Title Ch oter 9-1115 3 and the Standards of San Join County Public Health Services,Environmental Health Division <br /> ei+v+�h,a+/�i�`4+t- Assessor's <br /> WELLLocation I&Y16 -5` Cross8trest t''`�f'y cu City 'c°f Zip Nf` Parcel# nra <br /> CM Or LA-W4-OP =A+r.t�l P�ALC 1�xc. e N 4v- <br /> -Address--j N PROPERTYOwner City Zip Phone# <br /> C-67Contractor_6.ScA'� t=tsa,n•� �nC ess3�`j S4� rtltSP��cL'r Ci1y5fAj alp 5L57-Llc# f�Phone#CZ04�`)7Z-35'7) <br /> S�co� S.r�awrrw�..c_ 3 ot'7 2R^ #sS'`i'f 18' <br /> Consultant/Sub Contractor_ �- - Address 1�i tgo�' �� City[exoo�'a Llc Phone#0 i6Yi-Lt-pYo O <br /> GIS Coordinates X ~ Y �`''p` ,Township Range N 0`'' Section <br /> W_ORKTO@EPE E <br /> ANEW WELL Rl (CP GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION(choose type below) <br /> 1NG# 6P- Z `*,5_0 �' Tf OVER-BORE <br /> WELL# d PRESSURE GROUT <br />"Other V A'' i*,;S C-)GDf ioG� C�c+icc.aSS ,P t.uc izc c w+ -T it ut Specifications1 �'ro"' ' <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 13 MONITORING a HOLLOW STEM DIA OF BOREHOLE 1 S MULTIPLE CASINGS?a YES p NO WELL CASING DIA <br />(I EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS AJ Ar TYPE OF CASING []STEEL Q PVC []OTHER N414- <br />(]VAPOR I7 MUD ROTARY DEPTH OF GROUT SEAL_ .yA TREMIE TYPE TO BE USED []AUGERS p HOSE <br />(I AIR SPARGE PUSH POINT GROUT SEAL PUMPED p Yes p No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br />'SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> R, n OTHER APPROX BORING DEPTH i 5 r p BOLTED TRAFFIC BOX or I]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? AJ^ (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 Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x y° - -- ----Tiile/Company_ 51`r4c� C� oc,�s7`, 5e cell- :C'fztvu" r�o� <br /> Print Name _T � -Date-7-1a N O Z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: - Z7 —02�, <br /> Application Accepted By Date Issued � Z Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS. <br /> ACCOUNTING ONLY AID# Fera <br /> 41E CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />