Laserfiche WebLink
y � tiJ <br /> WELL PERMIT APPLICATION =ORM SITE <br /> MITIGATION <br /> �•/;f --��� SAN JOAQUIN COUNTY UNIT!V <br /> t"['T ENVIE MENTAL HEALTH DEPARTMENT (EHD) <br /> 20A E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3448 <br /> UC-, NbN•REFUNDABLE PERMIT EXPIRES i 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 /> .r Joaquin County Development Title.Chapter 8-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors 0 <br /> WELL Locatlon. Q ��Q✓�Y /��" Cross Street Z���- .5 City ��� ZipPar`�t# 6' <br /> PROPERTY Owner '� _Address _.�?ry+t P City Zip-____--Phone how 2/ <br /> y C-57 Contractorf/g'',' Address'00 A.e 9�d CitygggW4 Zipy'Lic# Phone# 2a <br /> Consultant I Sub Co�ntracior4r84'104#f gr a —Address �(�v�ucm►d-r City�Lic#Phone# ` ` 4293 <br /> V <br /> GIS Coordinates:X ,Y ,Township Range Secilon <br /> WORK TOB ERFORMED: <br /> 11 NEW WELL l BORING(CPT.GEOPROBE,HYDROPUNCH,BAND-AUGER,OTHER`) ESTRUCTION(choose type below) <br /> Q SOIL BORING# ER-BORE <br /> a WELL# JFESSURE <br /> GROUT <br /> "Other: Grout Specifications: "—/e,Cy <br /> COMMENTS: /f ee3 fU 2 m e6 24 ��✓ '~ �' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING Q HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?Q YES n NO WELL CASING DIA: <br /> Q EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: g STEEL [I PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: q AUGF_RS Q HOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: 11 Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: <br /> Q QT}{ER.. Q OTHER APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX or Q 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 /> .. t hereby certify that 1 have prepared this application and that the work will tae done In accordance with San Joaquin <br /> County Ordinances,Rules and Regulations,and all applicable California State Laws. <br /> `..r Signed x <br /> TitlelCompany�L � <br /> Print Name �-d'"t � r� Date .-- <br /> ��l EPARTMENT USE ONLY_ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Date Issued Date.-------- <br /> Application Accepted By Date Final Inspection By <br /> Grout Inspection to <br /> Destruction Inspection By Date <br /> y COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# car t� <br /> V <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 6,190 <br /> C-57_ WC :WAIVER____ C-57 Letter of Authorization to sign permitr.Encroachment doc_ <br /> 1/25/Qz <br /> (7j-) W�� <br /> 1r <br />