Laserfiche WebLink
WEL,- PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> Q 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 /> Assessor's <br /> WELL Location(S33 S- 5-6k, -,, I� Cross Street Ql�I to (City LJ L Zip �4�a y l Parcel# <br /> PROPERTY Owner C I l` /AlOX(�-�4I! - Address)1 nrjurxdSl�nr'eS L.ciy p • G Zip I/,y�(,ys Phone#(D4 y(,(i-0I0y <br /> C-57 Contractor tktvYP� IkUIn;r�ne ddress �3� S�IG�✓P CityS�Y,K ot) Zip` Q Lic#6eO0 117 PhoneA��� <br /> Consultant/Sub Contractor ;/gs , _Address CityLic# Phone# <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> OIL BORING# S 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS p <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE��MULTIPLE CASINGS?0 YES ONO WELL CASING DIA: /J <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_V_TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: � <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL toiir-z TREMIE TYPE TO BE USED: 0 AUGERS <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes IkKo (NOTE: MAXIM UM,FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: �y I O ��^4 f r)( �I G1^ —fU 6 Ga lon <br /> 0 OTHER:_O OTHER APPROX. BORING DEPTHS' J- 0 BOLTED TRAFFIC BO or 0 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi ces, Rules d Regulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name �� CiY� /"`I II l�.N�6V1 Date O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued/0Area C-5A <br /> Grout Inspection By Dat jj�b 1 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> I <br /> 0 6 �-�I �i S <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc 9/27/00 <br />