Laserfiche WebLink
WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <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 /> Jin Coun for permit to construct andfor install the work described. This application is made in compliance with San Joaquin County <br /> Application is hereby made to San oaqutY Pe <br /> Development Title.Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department, Assessors <br /> WELL Location <br /> (� 1�Cross Street_m City `1q —zip�Parcel# r <br /> PROPERTY Owner"A !F �-� Address a Ir{I <br /> City _zi 3 O Phone# <br /> C-57 Contractor.. tT� ` ` —Address CitZrag— g52l Liv# Phone �ff� �'7- <br /> 0(p <br /> Consultant l Sub Contractor Q-Cx Address K a Cit�6 ��Lic# Phone# ��{ <br /> 0 <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> ORK TO BE PE MED: DESTRUCTION(choose type below) <br /> NEW WELL/ RIN (CPT, OPR E,HYDROPWCH,HAND-AUGER,OTHER') 0 0 OVER BORE <br /> L BORING# S [�PRESSURE GROUT <br /> W ELL# <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING O HOLLOW STEM DIA.OF BOREHOLE Z� --MULTIPLE CASINGS?0 YES Q'NO WELL CASING DIA: <br /> 0 EXTRACTION AIR HAMMERfDRtVEN CASING THICKNESS_TYPEfOF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALT'JZ&b[P_g TREMIE TYPE TO BE USED: []AUGERS AHOSE <br /> 0 AIR SPARGE *P'USH POINT GROUT SEAL PUMPED: Kes 0 No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> fJZ- <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specificatiohere}: <br /> DSE ' i3 <br /> A <br /> 'COMMENTS _ S <br /> y Y <br /> NOTE: OFFSITE BORINGS RE DIRE 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 prepay d this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> Rules and Regul tions an a livable California State Laws. <br /> Signed x <br /> Title/Company <br /> Print Name Daie 1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> r ��102 <br /> Application Accepted Byfe_b� �ti Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY. AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY 1DATE PERMIT!SERVICE REQ//UErrST# INVOICE <br /> jL ] SR# <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit^Encroachment doc_ 1/25/02 <br />