Laserfiche WebLink
04/04/2002 13:04 20946834 FIFTH FLOOR • PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (F-HO) <br /> E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 4683449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 9LSUED <br /> - <br /> Application is hereby made to San Joaquin County for a Permit to construct andlor 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 /> �sessor's <br /> WELL Location s2 r72'7 ('ones 7 ��:�/'� ass street city % .cc zip 727& Parcel# r�r7 <br /> PROPERTY Owner Address PO_ P%;Iy- qrs� City r4p Phone#_(. /%- 9sg— �� <br /> �rrii <br /> C-57 ContractorJAddress P.C- �r E 09 3 city hlr��Y Zip 7��/�Lic#2I ,LO&Tphone#S3�''�, ZO/� <br /> Consultants r 6` f.cPry.�e�Address '7770 2r I-1 City 'LI �C NL.._Phone# �lh-ti 'uF� <br /> GIS Coordinates:X ,y..Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> ,n,NEW WELL/BORING(C GEOPROB YDROPUNCH,HAN D-AU - ,OTHER-) 0 <br /> 9, <br /> ING# / 2 3 c% 7 Q OVER-BORE <br /> U WELL# n PRESSURE GROUT <br /> -Other: Grout Specifications- <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTIONS GIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE I it MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:_ <br /> []EXTRACTION 0 AIR HAMMERlDRIVEN CASING THICKNESS TYPE OF CASING: U STEEL U PVC 0 OTHER: <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS I7 HOSE <br /> a AIR -jFUSH POINT GROUT SEAL PUMPED: Il Yes 0 No <br /> I(NOTE: MAXIMUM FREE-FAL DEPTH IS 30) <br /> []SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> Q OTHER D OTHER APPROX.BORING DEPTH - BOLTED TRAFFIC OX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (H 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 OrdInAlrices,Rules and R g lations,and all applicable California Staatte,Laws. <br /> Signed z Title/Company <br /> Print Name `- rytl/'`{S NDatelY_�� d�Z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,AD <br /> 3RESS: <br /> WORK PLAN DATED: <br /> Application Accepted B ✓rn/1 Date Issued 4 I I oZ I,-,�_ Area <br /> Grout Inspection By yy <br /> Y I!-i— <br /> Date Rnal Inspection By Date <br /> ?/ <br /> _Destruction Inspection By 41 4 Date a d <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# carft <br /> PE CODES FEEINFO AMOUNT REMrrrEO CHECK# RECD BY DATE PERMIT I SERVICE REQUEST INVOICE <br /> 2�i�1 $5 ��1 3x333 6 SRIt � 9N32 <br /> 5-57_ WC=WAIVER_ C-57 Letter of Authorization to Sign permit,Encroachment do;_ 1/25/02 <br />