Laserfiche WebLink
WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> b ENVIRONMENTAL HEALTH DEPARTMENT (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 Environmental Health Department. <br /> // \ Assessors <br /> WELL Locationn�NQ /a ti 2 u a d Cross Stree(]����'Z City L C-tti�oP Zip Parcel# _ <br /> `✓c�Sf��tidS �4v�Wa� <br /> PROPERTY L ooi L 3 V(o 3 -2­3 <br /> 0 <br /> w er c4c� �n�tfo r Address G°/ S. F� !Le-0-0- City °S a Zp�Phone# (SSS <br /> G� W sy/. n ft.s t.�F U fto J 2 Z 66 �\ <br /> C-577 Cgotractor Address P C' oK ip'rJTct-+e# Phone#[—�J <br /> Consults /S <br /> ub Gntr F'S—d W-j Address/(JOU ro adw a c, City GG Lic#GC6� Phone# I S/1)� 2 G 7 <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> `(SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 6" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_O OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR 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 Ordin nces, Rules and Regulations, and all applicable California State Laws. <br /> Signed x <br /> D`r Title/Company���`c,�!° /��£✓v L✓ J� /h c, <br /> T ^� <br /> Print Name u, �I �a in.G. Date �c/cc.-r*-�(.�-'� /� '2••0e 3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued �eQ, I , �" Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: re It <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D 13DATE PERMIT!SERVICE REQUEST# INVOICE <br /> ZDJrg� /z/ a sR# 3 � <br /> C-57_ WC=WAIVER C-57 Letter of AuthqAzati n o sign permit_Encroachment doc 9/30/02 <br />