Laserfiche WebLink
d� D <br /> prr)) <br /> WELL PERMIT APPLICATION FORM <br /> CR' <br /> fiSAN JOAQUIN COUNTY MITIGATION <br /> t� C , ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> . 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 Ong <br /> NON-REFUNDABLE PERMrr 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 /> WELL Locatlan g T Cross street F;f�T 57 _city 6T0 jGw— zip Y5 ao'�Par�l IS3-a8a-.odg <br /> PROPERTY Owner'rggn&W Address •0.Bax 7 City t !2kP Zip Srr� Phone# <br /> C-57 Contracto illi 4tty Mdre _city ;f¢z zlpf"ma ic# Phone#p <br /> a <br /> Consultant/Sub CntraMbr1 v71t'M ressoZSpe&I <br /> GIS Coordinates X ,Y Township Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) El DESTRUCTION (choose type below) <br /> R'SOIL BORING#68-12.65'13 -15 []OVER-BORE DIAMETER <br /> I]PRESSURE GROUT <br /> [I.Other L GROUT SPECIFICATIONS <br /> COMMENTS ` <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS p <br /> XMONiTORING ICHOLLOW STEM DIA OF BOREHOL I]MULTIPLE CASINGS I]MULTI-LEVEL W ELL CASING DIA. D? <br /> EXTRACTION []AIR HAMMER/DRtVEN CASING THICKNESS A qQ TYPE OF CASING [I STEEL JfPVC []OTHER <br /> a VAPOR JCMUD ROTARY DEPTH OF GROUT S TREMIE TYPE TO BE USED [i AUGERS ]HOSE <br /> AIR SPARGE/OZONE []PUSH POINT(GP or CPT)GROUT SEAL PUMPED 'g Yes [I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING []HAND AUGER GROUT SPECIFICATIONS t 6'eOt4T <br /> []OTHER� _[I OTHER APPROX BORING DEPTH'iK'iWS 100 ' BOLTED TRAFFIC BOX or [I STOVE PIPE <br /> • CONDUCTOR CASING PROPOSED (d YES,list specifications in comment section) <br /> COMMENTS 11 IM-NS" W 4 CCV4 )jn5 4OtOA TO IJ ' M&A <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San.Joaquin <br /> County Ordi nce ulations,and all applicable California State Laws. <br /> Signed - - Title/Company <br /> Print Name_- rl �' V n L.! --Date Z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 2 f A& GD <br /> WORK PLAN DATED: 0 2- e4-Zo•oZ <br /> Application Accepted By Date Issued <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS' <br /> ACCOUNTING ONLY AID# FAC# <br /> E CODES FEE INFO AMOUNT REMITTED CHEC/K# REC-D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> f fi7 �Or SR# 003C& <br /> C-57 1 WC -WAIVER C-57 Letter of Aut�lzati t sign permit Encroachment doc 9/30/02 <br />