Laserfiche WebLink
W <br /> WELL PERMIT APPLICATION FORM 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 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> WELLLocation EyeAyy% //�� ,Af C ` Assessor's, <br /> ((++ Avenve. Cross Street rDrt-er rCV�'. City Jroc]C-�0 r Zlp Parcel# i t'-d£ <br /> PROPERTY Owner I+ of S+ac4C-i'" Address CI " Rai I CI �T ktbVN Zi 3 Pu `ti s. r<g <br /> ty . ec __2P;?_p $ Phone# Q3^I ^ 8 (033 <br /> TT 16 ) <br /> C-57Contractor VP Yt DrIlItAo "TwAddress loo P% 4! k S+rem City io � ZipgSkIL is#7 !q'?* Ph e# '7 "1'7 - 4flPO <br /> Consultant / Sub Con[ractorCone�or Earth T@cL. �Ti'rP.lddressJ $`3' Fym,& K1 .VesjDr�Ity Sjmo k'tavruc# Phone# 0234 —b '$IS <br /> GIS Coordinates: X . Y , Township 42N $te :r Range to E Section <br /> 2.1 <br /> WORK TO BE PERFORMED: <br /> h1EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER`) D DESTRUCTION (choose type below) <br /> D SOIL BORING # _ p OVER-BORE <br /> 0 WELL #_ . _ [] PRESSURE GROUT <br /> . <br /> IAn <br /> `Other: Mn Yti �'t'OY' 61A Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL , ` �r %3INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> q*ONITORING C"j OLLOW STEM DIA, OF BOREHOLE g •r MULTIPLE CASINGS? BYES [] NO WELL CASING DIA:42 <br /> D EXTRACTION D AIR HAMMERIDRIVEN CASING THICKNESS 3eh• 40 TYPE OF CASING: D STEEL YPVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL Ra r— 4q TREMIE TYPE TO BE USED: AUGERS H HOSE <br /> D AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: �, �� Nu U <br /> D OTHER: D OTHER APPROX. BORING DEPTH T� (/r BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? --�( i 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 and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED : <br /> Application Accepted By Date Issued Area <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 IN FO AMOUNT REMITTED CHECK # RECD BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />