Laserfiche WebLink
I 1 <br /> WELL PERMIT APPLICATION FORM 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 /> r ` 1 - ` Assessor's <br /> WELLLocation `5l5 GMM (n tf e; Ro J Cross Street 6 �1 Uv d City �Zipssi3no Parcel# <br /> PROPERTY Owner��kp&At EJa � le � tnd,...n Acddress1l(AMI & \ 2' li ^vuw 0, (City Spr �a+No�� Zip945$3 Phone# 9L5SS4Z - 9/nS� <br /> C-57 Contractor 2��` tvt Address 1� t6%& 'C.!) City wSiKeZ-" ZiplgM Lic#6SZyo1 Phone# ?IS 313 SIM <br /> UU <br /> Consultant / Sub Contractor 5 Address 3611 kiloelZ City}I & Lic# Phone# I^OgL0 <br /> GIs Coordinates: X , Y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,[]NEW WELL / BORING ( CPT, GEOPROBE, HYDR PU CH, HAND-AUGER, OTHER') [] DESTRUCTION (choose type below) <br /> _SOIL BORING # e e_ [] OVER-BORE <br /> U W ELL # [] PRESSURE GROUT <br /> *Other: GROUT SPECIFICATION <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [] MONITORING [] HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? [] YES dNO WELL CASING DIA: t� A <br /> [] EXTRACTION [] AIR HAMMER/DRIVEN CASING THICKNESS N TYPE OF CASING: [] STEEL [IPVC [] OTHER:Ak— <br /> [] VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL Q TREMIE TYPE TO BE USED: [] AUGERS []HOSE <br /> [] AIR SPARGE [] PUSH POINT GROUT SEAL PUMPED : [] Yes I[] No (NOTE : 1M_ AXIMUM FREE-FALL DEPTH IS 30') <br /> /SOIL BORING [] HAND AUGER_ GROUT SPECIFICATION I,2.K1�r �Y>l <br /> [] OTHER: OTHER Ct' APPROX. BORING DEPTH '�h r [] BOLTED TRAFFIC BOX or [] STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br /> COMMENTS: <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <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, State Laws, and Rules and Regulations of the San Joaquin County. <br /> * CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x Title/Company <br /> Print Name Date <br /> SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED <br /> DEPARTMENT USE ONLY /I <br /> Application Accepted By Date Issued / Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By /1 Date/ <br /> COMMENTS / CONDITIONS: C• � ' /Z�'- �9r �-�l � /� / <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK It REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 0595/ �S r�5 X30 ( t a1 sR# ooI r t <br /> C-57_ WC/WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/12 /00 <br />