Laserfiche WebLink
08/15/2000 12: 07 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SEF I� t4tT IVTION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br /> 304 E. Weber, Third Floor, Stockton, CA., 952qgjG 17 DOO <br /> (209) 468-3449 <br /> RONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS �4��ER\XES <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This I n 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 /> r1, A �J2� WOrI<Pl�ti� <br /> WELL Location 7 I Sr��� /1�5 ,� }i� Cross Street �iS2r P,A City Slee: o In Zip �� Parcel# <br /> U'urii 5t�a /�or><�trh SnK/q <br /> PROPERTY Owner F-- �a;1�> �o dress 7,V �. �Nr�rr e Ar. City Sw� L�r�.pr�rna_Zip. �4`f�0 Phone# 0' <br /> PROPERTY <br /> ' <br /> � llLic# 7�7Sl0Phone# <br /> CS7Contractor Address City ZP <br /> �J <br /> Consultant Sub Contractor, TlZ� Address �05� tvh.rrtiF� lr, CIryC�NLvr ( Lic# y0y44 Phoney <br /> GIS Coordinates: o FG/e Township Range Section <br /> X .�' <br /> WORK TO BE PERFORMED_ <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> #WELL## M W - I 0 PRESSURE GROUT <br /> 'Other: GROUT SPECIFICATION <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> j MONITORING 0 HOLLOW STEM DIA_OF BOREHOLE %n. MULTIPLE CASINGS?0 YES 0 NO WE"CASING DIA; <br /> 0 EXTRACTION 0 AIR HAMMEFUDRIVEN CASING THICKNESS Sch. �O TYPE OF CASING: O STEEL N PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL__y5-2 t• TREMIE TYPE TO BE USED: N AUGERS []HOSE <br /> []AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: N Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATION %rta, f <br /> 0 OTHER; I]OTHER APPROX.BORING DEPTH iIO �L�/ II BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? No _(if YES,list specifications here)' <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. <br /> *CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x ITitlelCompany S�nu t t ��v�c e i, / /� <br /> Print NameG S• <br /> SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED Y-- 0 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By , '- Date Issued e'' w Area <br /> 2- <br /> Grout inspection By Date­i—/2- /vJ Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDrrIONS: ✓" ( �/v►�c�ti�/�'�' '✓' r r'`yy,/X wG "-L,441—,I ft ` <br /> K 1 �Z� <br /> ACCOUNTING ONLY: AID# <br /> PE CODES I FEE INFO AMOUNT REMITTED CHECK# REG'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC/WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 7/17/00 <br />