Laserfiche WebLink
o WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> UNIT IV <br /> JUN 0 6 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) - <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (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'-11105.3 and the Standards of San Joaquin County Environmental Health Department. <br /> �00 25)0 r� LbG� ! rt1� 'r )) � Q p4 Assessors <br /> WELL Location Cross/St�reJet rTl fill��'��City �p/" 1Zip I �� c�,�.�Parcel# <br /> PROPERTY OwnerE�� I t—© , AAddress��'"' �Q' P;� City f t��/C' Zip --2 0Phone#5SS 6 00 <br /> C-57 Contractor fee_ �rl S� Address n QV "'T� C it �4 Zi�T s i*56 r a7Phcne#Z53/3 —'509D <br /> Consultant/Sub Cntr 67 1115� Address 46_3? S Am t4 'P(ityS1kAj Lie# Phone# 1§0 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ) NEW WELL 1 BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") DESTRUCTION(choose type below] <br /> 4 []SOIL BORING# [I OVER-BORE i <br /> 1]WELL# []PRESSURE GROUT <br /> `Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE/�Z " LTIPLE CASINGS? MULTI-LEVEL?a WELL CASING DIA:N14 <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS N+h- TYPE OF CASING: []STEEL' ,IPVC []OTHER: <br /> []VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL FffX!6-7 TREMIE TYPE TO BE USED: []AUGERS 0 HOSE <br /> a AIR SPARGE 1 Ozone/PUSH POINT GROUT SEAL PUMPED: R11'es a No (NOTE:ppMAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING []HAND AUGER GROUT SPECIFICATIONS: <br /> []OTHER: []OTHER APPROX.BORING DEPTHAO ]]BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCC30R CASING PROPOSE Dr� (if YES,list specifications here): <br /> " COMMENTS: oI C?e T p�IL/ f <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. A" <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 QA� Title/Company <br /> Print Name_/ykarn L2• - Dat /t.-5/ �i <br /> --DEPARTMENT USE ONLY <br /> . i <br /> SITE MAP IN UNIT IV FILE,ADDRESS: s <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued l A7 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS l CONDITIONS: � Saw 61 L✓ � lc�� C� S /Lt P <br /> ACCOUNTING ONLY: 'AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# ` INVOICE <br /> uol­ '1,31 . [5�� — OSA:9 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br />