Laserfiche WebLink
WELL . ,ERMIT APPLICATION F. M <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 />MITIGAi;ON <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 Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessor's <br />WELL Location _ �S 7d cf%Cross Street &—X— � <br />/ ity ��Zip � QP��cel# IO I— Z 3 d L <br />PROPERTY Owner /3/rte /%/46�zj+ Address �� %'�/X 7j�(O City Zip 2j —W_wk;? <br />C -5'i Contractor !/� Address D✓4/ 7 �/�Cityii s Zip � c# (O�Ti'7PRone#/ 17161(� _ <br />Consultant / Sub Cntr <br />Address <br />City <br />Lic# Phone# <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFCRMED: <br />0 NEW WELL/BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) p DESTRUCTION (choose type below) <br />SOIL BORING #_� 0 OVER -BORE <br />WELL # _ PRESSURE GROUT <br />*Other: <br />COMMENTS <br />Grout Specifications: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE) ~ MULTIPLE CASINGS? 0 MULTI-LEVEL? 0 WELL CASING DIA: 4� <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS U4- 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 AUGERS 0 HOSE <br />0 AIR SPARGE / Ozone PUSH POINT GROUT SEAL PUMPED: 0 Yes Ki to (NOTEE:"MAXINIUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br />0 OTHER:_______ -0 OTHER APPROX. BORING DEPTH I 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />_ CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): � <br />*COMMENTS: IVl p QLA I fZF (> <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 OrdZj <br />ces Regulatns, and all applicable California State Laws. <br />Signed x Title/Company <br />Print Name_ V 14-rDate 3 a' S /A' <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: S �� tnno►17� S+ S'b� <br />WORK PLAN DATED: i <br />Application Accepted By Date Issued 2 Area _ <br />Grout Inspection BDate O Final Inspection By Date 03 <br />Destruction Inspection By Date <br />COMMENTS / CONDITI <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT/ SERVICE REQUEST # <br />INVOICE <br />35-01 <br />Isgq.00 <br />1$12 <br />0 <br />32-clo Z <br />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br />d <br />9 <br />(t <br />0 <br />