Laserfiche WebLink
WELL PERMIT APPLICATION FOrcM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT(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 /> 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 Joaquin County <br /> Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> Assessor's <br /> WELL Location w. L6e1tJ N&SA-, Cross Street City I-OCI; Zip Parcel# Q <br /> PROPERTY Owner /U VIL'I Address o&-)( 7S3 CitylZip J�23 Phone# 20 <br /> � 7'/69V <br /> C-57 Contractor L Address. lt7 e ,, CityZip gg);Lic#A hone#� 1(0 <br /> I'100 <br /> Consultant/Sub Contractor Address�7S�tlu& CitydUc#(oR0117Phone# 467-IDo p <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> . NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> .'SOIL BORING# OVER-BORE <br /> 0 WELL# PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z�r MULTIPLE CASINGS?0 YES )(NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS—.IV' TYPE TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER:_ <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL€^V-�r-<— TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE x'USH POINT GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: PLOY P1'1,� <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH_ !-XP r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?4k—(if YES,list specifications here): <br /> 'COMMENTS: <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 County Ordinances, <br /> Rules and Regulations,and all appli able C lifornia State Laws. <br /> Signed x / 1 iitle/Company <br /> T I S <br /> Print Name V A n l-e I 1/��r �� -�C' C►1 _Date :71102- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: MEj�C <br /> WORK PLAN DATED: ZAP ZaV - S <br /> Application Accepted By f �v` Date Issued ( Z2 O L— <br /> a <br /> Grout Inspection By Date Final Inspection By Date <br /> OSI G S <br /> JOPQpUL�S��\"\NN <br /> Date <br /> Destruction Inspection By nN �F <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING qFEEINFO <br /> # FAC# <br /> PE CODES OUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> l� 2-1 7l�-a oz SR#D030(os? <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 1/25/02 <br />