Laserfiche WebLink
FILE COPY <br /> WELL PERMIT APPLICATION FORM 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 O vw 'p <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. Assessor's <br /> / ' f A /� AciFit• Ave , <br /> WELL Location " / J & FFII T/Vkwcross Street(3 ' n.,- H ' ST. City 5TPCKTn+`1 Zip SZ 7 Parcel# 1/ O�Z /3 <br /> pew 1490 k ; NARAe NF CYQ`r) <br /> PROPERTY Owner /✓11GhC4e1 f�'lOnySSQfo Address y City 1x01 ZipgSzy ZPnone# 36$ A/ �� <br /> N W To 415415 1 LicS <br /> C•57Contractor5+Er? ExnefuitDnAddress P100 Box b ` CilyspA4AZip 521 <br /> bPhone# X1674 <br /> $57 SNA .vAD CitySjccKLic# 6? oZZ7Phorie# 20 ' oD <br /> 6 <br /> Consultant / Sub Contractor n . 6 • r Address <br /> GIS Coordinates: X., Y , Township d rJ Range <br /> 1U I� Section <br /> WORK TO BE PERFORMED: . DESTRUCTION (choose type below) <br /> �i NEW WELL / BORING ( CP T, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 p OVER-BORE <br /> I` 0 SOIL BORING # <br /> AWELL # Iw ^ IiVw• i fQ�r ^ I �(_ l+.^ I .r-� SUREGROUT <br /> 'Other: Grout Specifications: � o TIPlvD r <br /> COMMENTS SFr or) P El) VvOfl� IA QATf..O � S � (SR Cr _I enz <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> q !l !I <br /> aMONITORING `HOLLOW STEM DIA. OF BOREHOLE$!= / 0r/ MULTIPLE CASINGS? 0 YES NO WELL CASING DIA: y. <br /> )(EXTRACTION 0 AIR HAMMER/ORIVEN CASING THICKNESSScpp44 <br /> ppnvla TYPE OF CASING: 0 STEEL PVC D OTHER: <br /> -jk`VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Sf- T SSG TREMIE TYPE TO BE USED: NAUGERS 0 HOSE <br /> j AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes ro (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING p HAND AUGER GROUT SPECIFICATIONS: D rf1A y0 TYpC 11 <br /> p OTHER: 0 OTHER APPROX. BORING DEPTH !tT 6 SG )�TOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?.N C, ( 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 applicable California State Laws. (� <br /> Signed x � Title/Company PRO�EC r e% st <br /> Print Name IA� hT/J� � . � VQ� It �' Date__5 <br /> ��".��'n <br /> DEPARTMENT USE <br /> USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : / [ a5 pi `s` <br /> WORK PLAN DATED : Z I `� ' O Z <br /> Application Accepted By �— Date Issued _ — rea <br /> Grout Inspection By Date anal Inspection ate <br /> Destruction Inspection By ate <br /> COMMENTS I CONDITIONS: <br /> =ACCOUNTING AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> ?66) 1 NW el/ Ab 75 ? SR# 00300 z <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit ✓ E. "'--"` a c 1/25/02 <br />