Laserfiche WebLink
WELL rrERMIT APPLICATION FOKM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> UNIT 1V <br /> ENVIRONMENTAL HEALTH DEPARTMENT (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 Environmental Health Department. <br /> 3 Q V L CTG( X17 Ct_VF r L.OD / Assessor's OS <br /> WELL Location Cross Street City Zip Parcel# 04 ct - <br /> PROPERTY Owner No RM C 9 V -I Address q3 2':Z PE:'5(5'X BGf*City SSC KMA')Zip �Phone# � $�4`f1'Z <br /> C-57 Contractor Vlt �RtLu^�G Address /DO -STS 'T, CitylSLcTt]N Zip95841 Lic#Q9o�Phone q�b -1-17`4�oo <br /> 1z G <br /> Consultant/Sub Contractor(SpQyivz) Address 7 t� ►"!At"y S`r. City�� Lic# 50;t,3 Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION(choose type below) <br /> SOIL BORING# OVER-BORE <br /> WELL# M W0 PRESSURE GROUT <br /> 'Other: Grout Specifications: ^'r�"r c.E n ANT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS , <br /> MONITORING 'HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES�10 WELL CASING DIA: <br /> 0 EXTRACTION �0 AIR HAMMER/DRIVEN CASING THICKNESS D- y Q TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> 0`'-" )R 0 MUD ROTARY DEPTH OF GROUT SEAL 5'�c� r TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 'ARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH S 0 BOLTED TRAFFIC BOX or 0 STOVE FIFE <br /> CONDUCTOR CASING PROPOSED? (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 a R��% s- an all applicable California State Laws. <br /> Signed x r Title/Company j�6 23 G RCJ`�^r`� Z�1Zo f�✓�`ysLS <br /> Print Name G fr G C Date 1°f a 3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED/:/, }/ <br /> Application Accepted By (� `""" Date Issued 0-111-3 Area (q <br /> q <br /> Grout Inspection By /�- DateFinal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> A- JNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY D,,A�TE PERMIT/SERVICE REQUEST# INVOICE <br /> 1 2— <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 1/25/02 <br />