Laserfiche WebLink
WELL`PERMIT APPLICATION ARM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <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 Public Health Services,Environmental Health Division. <br /> Assessor's t� r� <br /> WELL Location "�S—0 Cross Cross StreetAT"v��'� ^'1 City !�✓ � Zip�Passes //6�^�S�'/l <br /> Al �A,t1 <br /> PROPERTY Owner 1,V 62UafAddress V, Zip 9sYft` Phone# by-fj(f- 3CLj <br /> C-57 Contractor Address CityZip Lic# Phone# <br /> Consultant/Sub Contractor Address City _Liicc# Phone# 1,7 <br /> /�y <br /> GIS Coordinates:X ,Y Township �� Range /\ [ (i Section !^/ <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> a SOIL BORING# B OVER-BORE <br /> B WELL# l)PRESSURE GROUT <br /> 'Other: Grout Specifications: - <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> PMONITORING p HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?BYES ONO WELL CASING DIA:_ <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC B OTHER: <br /> o VAPOR H MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: l)AUGERS 0 HOSE <br /> a AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: H Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> H SOIL BORING H HAND AUGER GROUT SPECIFICATIONS: <br /> a OTHER:_B OTHER APPROX.BORING DEPTH II BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: �itl9-tJ 1[O•'L(-'t1G GLItDCGS �G•'L �� C� q.c-6-5 <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 and Regulations, and all applicable California State Laws. <br /> Signed z Title/Company <br /> Print NameDate <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY I DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />