Laserfiche WebLink
WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-END) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> NON- (209) 468-3449 FILE COPY <br /> REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> kpplication 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 /> NELL Location \rev N \111 . L`2\-A�,�� ,l e,_ Cross Street�r��oY. . City�\�ti.�e cs. Zip �l3 �G Parcel# <br /> PROPERTY OwnerC-A��o-rrc� ���c� c Address Z� City ��r)tecg Zip S336 Phone# 2-�`�- -,\ 1 <br /> 0-57 Contractor \1't W Q2�\1•�Ok Address �;3u�t{``o Cites S\tsar Zip S .I L#�°�° Phone# \ 1� <br /> � Ibi�, <br /> uonsutt (Snb 6erttradtef Cjsi�\o��cy� 1 tc�r'��Asddress ��b\ �^ <br /> City- m cK Lic# -- Phone#Z U9 S 2Z`{1\nI <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED; <br /> It NEW WELL/BORIN G(CPT, c PRO - YDR0PUNCH,HAND-AUGER,OTHER`) [I DESTRUCTION(choose type below) <br /> I SOIL BORING# Q, P \ 3 <br /> a WELL# r F D OVER-BORE <br /> 'Other. Grout Specifications: a PRESSURE GROUT <br /> COMMENTS: ,L <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING J6 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?❑YES Q NO WELL CASING DIA: <br /> 0 EXTRACTION RACTION Q AIR HAMMER(DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL O PVC. []OTHER: <br /> ❑VAPOR I7 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:. [I AUGERS Q HOSE <br /> 0 AIR SPARGE [1 PUSH POINT GROUT SEAL PUMPED: 0 Yes 5 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> l�SOIL BORING 0 HAND AUGER. GROUT SPECIFICATIONS: <br /> II <br /> OT H=R: D OTHER HER APPROX.BORING DEPTH . 0 BOLTED TRAFFIC BOX or (I STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: \--r7 a <br /> C o \ c- c9. % <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, ule d gulaT-R tio and all applicable California State Laws. <br /> Sinned x TitlelCompany 1 t�kl- r Z S t�j r.� r�.Y st a 1n1 <br /> Print Name_ �( Y,�Z Ol � � O�r oyJ Date - - <br /> DEPARTMENT USE ONLY <br /> SITE MAP Its UNIT IV FILE,ADDRESS: L O U t'S Ma rt±e' ez a <br /> WORK PLAN DATED:-- R eene— z .2 2 b o 3 � /� <br /> Application Accepted By ,C r i a E�'lG Y Date Issued A ; 3 Z0D¢ Area f 4Sg <br /> Grout Inspection By � Cate 5��-6� Final Inspection By ate s- <br /> Destruction Inspection By t_ Date <br /> COMMENTS/CONDITIONS: 1 Y Co r G'p-I P- <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35"01 84.60 89. 00 0158 03 0037 8 38 <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc 9/27/00 <br /> co yDvd eJDMA H1dId <br /> EEt�E89bE0Z 95:FT. TG1Q7 ion 17ra <br />