Laserfiche WebLink
fI <br /> WELL ERMIT APPLICATION I= M SITE I <br /> MITIGATION <br /> SAN JOAQ'UIN COUNTY PUBLIC HEALTH SERVICES UNIT 1V <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-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 /> to San Joaquin Coun for a permit to construct andlor.install the work described. This application is made in:campliance with Sa.i <br /> li tion is hereby made q County A Environmental Heal:h Division. <br /> PP -1115.3 and the Standards of San Joaquin County Publi..Health Services,E <br /> Joaquin County Development Title,Chapter 9 Assessor's <br /> WELL Location 2$fly e• �GW O4 Cross Street h[s t City S-I`Oc�fioh zip Parcel# <br /> PROPERTY Owner I�tcSe 1 ddres5 0 City O Zip Phane# <br /> A <br /> C-57 Contractor ( u�o ra 1>r1�11yAddress R•a.eox —IS r. CityR o VLatc% Zipl?q571 .Lic#7jq0MF1hone# o – O <br /> Consultant Sub Contractor <br /> �v1G Address LnK� Pa * City Sfo Lic# Phone#_S`T4–Z7yl _ <br /> y Township Range Section <br /> GIS Coordinates:X <br /> WO BE PERFORMED DESTRUCTION(choose type belq�v) <br /> EW WELL BORING(CPT,GEOPROBE,HYDROPUNCH,NAND-AUGER,OTHER') © n OVER-BORE <br /> I3 SOIL BORING# I7 PRESSURE GROUT <br /> )kWELL#J., 5 <br /> ecificatiens:- on <br /> Grout Sp rB�c-rtt s <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION;TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING —'Z I3 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?[]YESNO WELL CASING DIA: Z i 1 <br /> EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS Scat O TYPE OF CASING: O STEEL pr VC 0 OTHER: <br /> `k4APOR 3 MUD ROTARY DEPTH OF GROUT SEAL 2 TREMIE TYPE TO BE USED: AUGERS HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Ikyes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING p HAND AUGER GROUT SPECIFICATIONS: C Co G <br /> COOt <br /> 0 OTHER: <br /> OTHER APPROX.BORING DEPTH (o S OLTED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? PJC) (if YES,list specifications here): <br /> 'COMMENTS: <br /> I NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />° CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> IE <br />'i I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Ruies and Regulations, and all applicable California State Laws. <br /> TitlelCompany <br /> Signed x <br /> i Date ESQ <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> f <br /> it Date issued `+ -..Area— <br /> Application Accepted By . <br /> Date Final lnsoeciicn By <br /> Grout inspection By <br /> Destruction Inspedion By Date <br />{ COMMENTS/CONDMONS: <br /> I <br /> ACCOUNTING ONLY: AID# <br /> a PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> k <br />{ 9/27/00 <br /> C_57� u/C_-WAIVE R C-57 Letter of Authorization to sign permit Encroachment doc. <br /> 0 <br />