Laserfiche WebLink
WELL PERMIT APPLICATION FURM FILE COPY <br /> °ECEWTEDSAN <br /> PUBLIC <br /> ENVIRONMENTALS UNIT IV <br /> VIRONMENTAL EA THDIVISION (PHS SERVICES <br /> JUL 3 0 2001 304 E. Weber, Third Floor, Stockton , CA., 95202 5 <br /> '= ACTH <br /> (209) 468 -3449 �� <br /> SEF H CES p r <br /> pERI �� .l NON-REFUNDABLE PER EXPIRES 1 YEAR FROM DATE ISSUED G ` ` q <br /> ApplicatiorV is hereby made to San Joaquin County for a permit to construct and/or install the work desuibed. This application is made 'n compliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental ealth Division- <br /> 6 rr ! p., Ass ors _ <br /> WELL Location I �1 Inn �..,,C((S-K�/1 �=r- � ���-� S gross Street s .f (G^��.�{�nnrl�Gr�- CityOu -ZU7� Zip /J 20Parce <br /> PROPERTY OwnerY pT ( _• �WL �.ddress 3a3 µ ' LtrLi. &vd Citys lcClCgftJ��-) Zi S ZO�Phone# <br /> n � p � 1� � � �. �/ ' ' f (<i >I'� Ci AQ1� Zip /7» J Lic# � =�07 Phone# - S�6fS � <br /> C-57 Contracto�Y k (! Address q, a t( �"` I p4' '!- '/ <br /> Consultant / Sub Contrector�/4 /lGFJ �rL(�,/1t1�� EetTalAddress � {�� Cit (kZar✓Uc# �� 7 Phonet# )Yb7 - 1006 <br /> GIS Coordinates: X., y.. Township Range Secticn <br /> WORK TO BE PE MED: DESTRUCTION (choose type below) <br /> ANEW WELL ORI G PT EOPROBE, HYDR UQP NC��AND-AUGER, OTHER') 0 0 OVER-BORE - <br /> SOIL BORING # f 0 PRESSURE GROUT <br /> WELL # <br /> *Other Grout Spedficaticns: - <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Aa MONITORING Il HOLLOW STEM DIA OF BOREHOLE Z MULTIPLE CASINGS? 0 YES kNO WELL CASING DIA <br /> 0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS_.( -�!1 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> T7AL TREMIE TYPE TO BE USED: DAUGERS OSE <br /> Il VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL D DEiPr�{ <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: KYes D No (NOTE: MAXIf UM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: 7/QeID <br /> 0 OTHER: a OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or ❑ STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?_ QID ( if YES, list specifications here): <br /> •COMMENTS : I POIGLAL/ JAI Fe ei ,S1O .C✓Ac.fG� Ob <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 1 ha prepared this application and that the work will be done in accordance with San Joaquin <br /> CountyyyanC$ a and Regulations, and all applicable California S�tLate/Laws. <br /> Signed x l Jy�)/ ,y• T1de/Companys/?/q u �1 A��" <br /> Print Name 1-/L ��ZK � Date 07120� � <br /> DEP�A/R'TMENTT USE ONLY <br /> SITE MAP IN OON <br /> UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED ' <br /> Date Issued�� kXWArea <br /> Application Accepted By - �(p• Off/ <br /> Grout Inspection By <br /> Date Final Inspec5on By Date <br /> Destruction Inspection By - Date <br /> COMMENTS / CONDrnoNs: <br /> ACCOUNTINGONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE PERMR / SERVICE REQUEST # INVOICE <br /> 35b ! S uu I IS7. I 402 Do <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ . <br /> 9/27/00 <br />