Laserfiche WebLink
6-N <br />WELL dERMIT APPLICATION FORM <br />NE pivErl <br />JAN 3 2002 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA.., 95202 <br />PERMIT/SERVICES (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 Puolic Health Services, Environmental Health Division. <br />Assessor's <br />WELL Location k.714 P-014 Cross Street Fre./i : , 11 cay 5-frck 716 ),-, zip ;I345- parcei# I "I 3 -2-60 - <br />PROPERTY Owner Owner c);) k-.2/N if Ill Z Addre-ss 06C Pot /F-i, Pi) City 6, , - fo C 4-071 Zip rA)07Phonett q 57 -YdS---:-) <br /> <br />i Address 1)R,' I-hi:Jr/6P City n e? zip q ycs3 'Jett 6.c,yo7phon40() 3/3-060 <br />C-57 Contractorii.- , Pr; illoc 1 ?C,:: <br />/ / i--- <br />Consultant / Sub Contractor t----- Address (-;),), 7 5 1,--y,,...,.., . City c.„+("). 4-1-/-rv„ Lic.1/ 2.2 7 Rhone# /7/ 2 j0()6 <br />GIS Coordinates: X , Y , Township Range Section <br />SITE <br />MITIGATION <br />U NIT IV <br />WORK TO BE PERFORMED: <br />4k-NEW WELL / BORING ( CPT, G PFROBE, HYDRCPUNCH, HAND-AUGER, OTHER') <br />, SOIL BORING # r( 5 <br />a WELL. # <br />Other: <br />COMMENTS: <br />1:1 DESTRUCTION (choose type below) <br />OVER-BORE <br />PRESSURE GROUT <br />TYPE OF WELL <br />a MONITORING <br />a EXTRACTION <br />El VAPOR <br />u AIR SPARGE <br />(SOIL BORING <br />OTHER: <br />INSTALLATION TYPE <br />a HOLLOW STEM <br />AIR HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT <br />fl HAND AUGER <br />El OTHER <br />CONSTRUCTION SPECIFICATIONS <br />CIA. OF BOREHOLE MULTIPLE CASINGS? fl YES [I NC WELL ASIN <br />CASING THICKNESS /1.,.<1 TYPE OF CASING: U STEEL fl PVC a OTHER: <br />DEPTH OF GROUT SEAL f-4-L,q.' TREMIE TYPE TO BE USED: AUGERS II-HOSE <br />GROUT SEAL PUMPED: ayes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: t:5 (-ti .•'!" 4-- <br />APPROX BORING DEPTH ? 5- 1:1 BOLTED TRAFFIC BOX or fl STOVE FIFE <br />CONDUCTOR CASING PROPOSED? AA if YES, list specifications here): <br />*COMMENTS: <br /> <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 Ordinance, Rules and.-Regulations, and all applicable California State Laws. <br />Title/Company (-)eCie I/ <br />Print Name DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: i Skc t cJc_-4ci-., <br />WORK PLAN DATED: 3 1 u t j <br /> <br />Date Issued I <br />Date it ) Final Inspection By (A Date lAc 444- Date <br />Area <br />Date <br /> <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br /> <br />kV( 4/`-- <br /> <br />• <br />LAJIIIIIVI=1,1 10 I touniul <br />k)(10;e3:)—*/ ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE P- - •• -...ri : • -. • <br />/ <br />INVOICE <br />3 CO I .0c, I C.c)9 14 i f - PZ stilt 01- c6 C i E <br />— I n /-17 Hin <br />Signed x <br />Date /VK <br />Grout Specifications: <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit ncroac men <br />