Laserfiche WebLink
WELL?ERMIT APPLICATION F M SITE <br /> TION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 96202 <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 <br /> _ <br /> WELL Location 3 .t i Cross StreetbWc ,,atj r,X City 5 f,,k4e,�, Zip!5- Parcel#Oq,?- 07 0 3 <br /> sy S fx wr 64'f+r f.1 1 ! r eN✓r 4 <br /> PROPERTY OwnerGGlCr•,o &eiNr sCor✓uri_f_'0 rlessGdC91 Yv��'N�pr t~ C€tySuy. omyA '75--SV <br /> /n� j�urrr L*v <br /> C-57ContractorCrCc,j,- IJ,jM,r -Address 3G 3,2 ���<c Circ-�C€tY2LE,- cyrr Z€p`15 79aLic#7 17 S/OPhane#9/6'6 �g`IIGy <br /> t?/vp Qua�1�o MI6-$6/-a <br /> Consultant/Sub Contractor s C e7 Address' D 7 jy c,P City �v«�ov�r _LIc# Phone#� Von <br /> GIS Coordinates:X ,Y ;Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> ]]SOIL BORING# -&OVER-BORE <br /> E]WELL# "RESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: 101,4f55 Li a ? a{ r ; l/ a4� � f �� 5`1-f - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE J'�MULTIPLE CASINGS?p YES ;[]NO WELL CASING DIA: a �r <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS ` 0. TYPE OF CASING: []STEEL Q PVC []OTHER:_ <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL :fj O TREMIE TYPE TO BE USED: []AUGERS a HOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: p Yes .0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: ltl ee/ eG-�e�7./ _ <br /> OTHER: ]OTHER APPROX.BORING.DEPTH_ Ga 17 BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR_CASING PROPOSED? 1*2 (if YES,list specifications here): <br /> 'COMMENTS: /I�{W ] NI ✓ra /"1 tN` W/ // b til cra o rr i r- <br /> 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 x Tit]e/Company <br /> Print Name Q- /14 r:L.4 c - Date ^` <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted 8y __Date Issued Z Z Area <br /> Grout Inspection By Date Final Inspection 8y Date <br /> Destruction Inspection Bya«f U l Date L _ <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# ner <br /> PE CODES FEE INFO AMOUNT REMrrTED CHECK# REC'D 8Y DATE PERMIT!SERVICE REQUEST# INVOICE <br /> -DZ �� 5z d�6 4: SR# y <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign.permit Encroachment dol 9/27/00 <br />