Laserfiche WebLink
• <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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 <br />Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location �1J /'i • / � Cross Street <br />/ /t X' k) Zip C asrce #or's <br />PROPERTY Owner 4iVts C.��z�i Address I* a7>�7%/*) City ` Ao f Zip 5�n <br />C-57 Contractor <br />Consultant / Sub Cntr <br />GIS Coordinates: <br />Zip Lic14Phone#. <br />w40 City_ tZJ Lic# Phone# <br />Y , Township Range <br />WORK TO BE PERFORMED: <br />0 NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />0 SOIL BORING # <br />0 WELL # <br />"Other: <br />COMMENTS <br />Grout Specifications: <br />Section <br />°DESTRUCTION (choose type below) <br />OVER -BORE <br />PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 MULTI-LEVEL? D WELL CASING DIA:_' <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS0 e <br />0 AIR SPARGE / Ozone 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: A, <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): (� <br />`COMMENTS: 4/eZ,f__ 2, <br />W -/ -_� f <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 Or nces, les -eta Regulati ns, and all applicable California State Laws. <br />Signed x p Title/Company <br />Print NameDate /L/ Z/ Z <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By_ <br />Grout Inspection By <br />Destruction Inspection By <br />DEPARTMENT USE ONLY <br />Date Issued�C <br />Date r j Final Inspection By_��,g 7�D� <br />Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />��� - �42� <br />PE CODES <br />FEE INFO <br />AMOUNT -REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />00 <br />C-57 WC WAIVER C-57 Letter of Authot;lzatici tb sign permit— Encroachment doc_ 8/29/02 <br />