Laserfiche WebLink
3 WELL PERMIT APPLICATION FU <br /> RM <br /> SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION ( PHS -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 <br /> Joaquin County Development Title, Chapter 9-1115.3 andtheStandards of San Joaquin County <br /> Public Health Services, Environmental Health Division. <br /> � (// b KGF e� `�-ty,31'0�(.' V`� Zi'I�� Assessor's <br /> WELL Location � oss Stre i p Parcel# 67`] ' 11 0 ' 01 <br /> X611 YDd�-'�S C�'rn� I _,� ?- _ [r� _ ._ -�, (� <br /> PROPERTY Owner D D CIX% A �esssl'!/Li n ` (� itx ]_Ill Com' Zip"I, _Phone � -�1�13 t� <br /> C-57 Contracto r Address' lCl "9Vnf, VOL . „C�i/l'y� � It _�"J�(� Liict& 5 phone g1 - J^)O' ) OD <br /> Consultant / Sub Contractor lre C.7GJF . �/lo-�Lik3FI IJ.IUV k Phones ` Z <br /> GIS Coordinates: X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ]�IEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH , HAND-AUGER, OTHER*) [] DESTRUCTION (choose type below) <br /> [] SOIL BORING # [] OVER-BORE <br /> Yd1]VELL # 1 [] PRESSURE GROUT <br /> *Other: Cl1P �&LIP _P L-iP I� 6X' Grout Specifications: <br /> COMM TS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING [] HOLLOW STEM DIA. OF BOREHOLE c MULTIPLE CASINGS? [] YES>UO WELL CASING DIA: <br /> [] EXTRACTION [] AIR HAMMER/DRIVEN CASING THICKNESS tr TYPE OF CASING: [] STEELVVC [] OTHER: <br /> [] VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ,AUGERS `]HOSE <br /> [] AIR SPARGE [] PUSH POINT GROUT SEAL PUMPED: Yes [] No (NOTE : MAXIMUM FREE-FALL DEPTH IS 301) <br /> [] SOIL BORING1AND AUGER GROUT SPECIFICATIONS: <br /> [] OTHER: [] OTHER APPROX, BORING DEPTH D 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 /> 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 d Regulations, and all applicable Californian S1taatte/ LLa'ws, / <br /> Signed \ ^ Title/Company �.�[(�1"'SsCI�P, I �l <br /> Print Name k�7 PA `�� �� Y YUI� Date lTl <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED : OC.T: Z 31 dO/ <br /> i <br /> Application Accepted By r/ Dale Issued ��� ( OZ AreatOPC05 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> SD� °o �� �lZ(o 7 / / / ✓ D/ SR 06 Zff 5-9 Z� <br /> C-57_ WC.-WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/ 27/00 <br />