Laserfiche WebLink
WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br />304 E. Weber, Third Floor, Stockton, CA., 95202 UHIU L <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 />Assessors <br />WELL Locatlol�f �j l 1N-�k Cross Street` City �, Parcel# �i I - I i <br />PE CODES <br />ff ��Zi� <br />rnS <br />PROPERTY Own��i/Y�tAr*DL'l )'�C�Addres !� O ✓ -[ 0 - Oit f%-fJ ip-c�' hone#� <br />CHECK # REC'D BY DATE PER ST # INVOICE <br />C-57 Contractor ��%ddress' Cit -- u'WZiP I' -&r)1 06� ^r.' Phone# <br />o �1 <br />Consultant/ SubContract i TrjL71ujkj,tlxtl-ff\P-Z Address 'in 1 �� Ct'Y-F���G�v CitC��"(lp'di'1ic# Phone#(/1�1�'J?l:�i'�i�� <br />GIS Coordinates: X Y Township Range Section <br />)IYORK TO BE PERFORMED: <br />) NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) H DESTRUCTION (choose type below) <br />SOIL BORING # Q OVER -BORE <br />$V ELL # X00 LAJ — a PRESSURE GROUT <br />/ <br />`Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? a YES -)&-NO WELL CASING DIA: l -�` � - <br />W <br />EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNES ,) 4C, TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br />VAPORMUD ROTARY DEPTH OF GROUT SEAL �t TREMIE TYPE TO BE USED: AUGERS Q HOSE <br />Q AIR SPARGE n PUSH POINT GROUT SEAL PUMPED: pYeslo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />Q SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: l L <br />[] OTHER:_O OTHER APPROX. BORING DEPTH i^o OLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />? <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 />hereby certify that I ha repared this application and that the work will be done in accordance with San Joaquin <br />County Ord' es, and Regulations, and all applicable California State Laws. <br />Signe Title/Company <br />Print Name s` \ LC Y 1 Iii �� �- ,� Date_' �7 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: IO I I I I a <br />Application Accepted By / ' ' , Date Issued Area <br />Grout Inspection By Date Final Inspection y Date <br />Destruction <br />COMMENTS / CONDITIONS: <br />Date <br />ACCOUNTING ONLY: AID# cerrfe <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY DATE PER ST # INVOICE <br />C-350 <br />o �1 <br />` <br />5q5 I �-' _-----CLSR#6 03 �S <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit achmentdoc 9/27/00 <br />