Laserfiche WebLink
WELL PERMIT APPLICATION FORM SITE <br /> UEC 2 1003, MITIGATION <br /> ENVIRONMiENI HLALI i SAN JOAQUIN COUNTY UNIT IV <br /> PERMIT/SERVICES ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMrf 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 9A 115.3 and the Standards of San Joaquin"C.ounty Environmental Health Department.Assessors ,f-_ �Z3V•oL <br /> �1 ,r 1 cr�r� STGL'1C]O'Zip g52o3Parcel# <br /> WELL Location X12.1 N'J�$u���`� � CrossStreet W- ��� City a� <br /> (pizR-E Is `rr' 3 <br /> ''��,,!! __^^ rt/ inRr7�2 Phone# - <br /> PROPERTY Owner�]L_fe�STbtCk7'VA1 —Address �25 N' F City 5?bGKTD Z' � <br /> s e <br /> city, " _ <br /> C-57 Contractor_ _ ✓�•• Aumcis IVEM Ci ��� 13� ���" -445''955' <br /> E O �'DOdJt¢Zr � hone# <br /> ({ C'03e ?w aMoglaEl �(�q,t.b Addressg''6-"r4o 5( City � Lics1r rL+ _ — <br /> Consultant/Sub/gontractor 1(2•-M <br /> %D""A D?Xo`% eC4 13'0-M4 Township Range Section <br /> GIS Coordinates:X •Y-- <br /> WORK TO BE PERFORMED: �DESTRUCTIO lb ) <br /> NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) R-BOR <br /> 0 SOIL BORING# RESSURE GROUT <br /> WELL# Grout Specifications: <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION PE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES ON <br /> WELL CASING DIA:_ <br /> AIR HAMMER/DRIVEN CASING THICKNESS _ TYPE OF CASING: 0 STEEL p PVC 0 OTHER: <br /> EXTRACTION O TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> #VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> _AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: O Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> HAND AUGER GROUT SPECIFICATIONS: <br /> 0 SOIL BORING D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH D <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifipatipns here). . I / <br /> *COMMENTS:— _- <br /> NOTE: urFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> G HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKIN <br /> hereby certify that I have prepared this application and that the work will be done in accordance with�SSaanJo.aquin <br /> County Ordina e� RuI a egulations, and all applicable California State Laws. <br /> (/ Title/Company <br /> Signed x Z 5 U <br /> L <br /> � -� Date /2 <br /> Print Name 4 Av% DEPARTMENT USE.:ONC ON <br /> C1, <br /> MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PIAN DATED: 12 I �� <br /> Date Issued (� Asea <br /> Application Accepted By ate Final Inspection By Date <br /> D <br /> Grout Inspection By <br /> Date <br /> Destruction Inspection By , <br /> COMMENTS CONDITIONS: r <br /> ACCOUNTING ONLY: AID# cera <br /> PE CODES FEE INFO AMOUNTREMn TED CHECK# RECD BY DATE - PERMIT/SERVICCE,.,RRE-SUEST# INVOICE <br /> 02 0 0 IZ 00 SR# 3 1/25/0 <br /> C-57_• WC—WAIVER_ <br /> C-57 Letter of Authorizati n o sign permit_Encroachment doc_ <br />