Laserfiche WebLink
l <br /> 5 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ..�.-- UNIT 1V <br /> ENVIRONMENTAL HEALTH DEPARTMENT(EHD) <br /> I 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3445 <br /> NON-REFUNDABLE PERMIT E=XPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andfor 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. " <br /> �5S fh� �ry Asse rs <br /> WELL Location Cross Street �r cit. ro Tjp ]37b "Parcel# 7 <br /> PROPERTY Owner Address_ D -t I t��Gity (R T�pS'S7G Phone#r <br /> C-57Contractor "Idl�' <br /> Address 1 0� ,t Me-r�, CityWtWZipC7/J Lic#T19V6PhonJ'61Consultant/Sub Contractor _ _ Address 10 City `'Lic#jj 7 Phone# V67"1ec)& <br /> GIS Coordinates:X Y Tewnship Range Section <br /> �WJDRK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) [I DESTRUCTION(choose type below) <br /> SOIL BORING# Q OVER-BORE <br /> + C3� o PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORINGFiOLLOW STEM DIA OF BOREHOLE I f 5 fc MULTIPLE CASINGS?d YES 0 WELL CASING DIA: <br /> EXTRACTION 11 AIR HAMMER/DRIVEN CASING THICKNESS _YO TYPE OF CASING: Q STE'E`LVC OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL a r S- TREMIE TYPE TO BE USED: kAUGERS a HOSE <br /> a AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: a Yes ) t<o (NOTE' MAXIMUM FIRE-FALL DEPTH 1S 30') <br /> ¢ <br /> g SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: r\ c j e"P7 <br /> Q OTHER:^ ��OTHER APPROX.BORING DEPTH_4L.0 r <br /> 0 BOLTED TRAFFIC SOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?/VO(if YES,list spedfications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT 1V 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 Rens, cl applicable Califomia State Laws. <br /> Signed x f TitfelCompany <br /> print Name M 1 t Date_� a 1d4 A) <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 50 Avkr V 100 <br /> Application Accepted BY C. Date Issued_"_ -•� 2 �+ `- �rea <br /> 3rout Inspection By Date Final Inspection By Date <br /> Loll <br /> Destruction Inspection By Date <br /> :OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMrr-ED CHECK# REC'D BY E <br /> PERMIT I SERVICE REQUEST ii INVOICE <br /> rf7l v f �� '1-I07- SR# 125r' 36 Z�� `1TaS3 <br /> C-57____, WC -WAIVER_ C-57 Letter of Auth iza on to sign permit`Encroachment doc_ 1/25/02 <br />