Laserfiche WebLink
• • - <br /> WELL PERMIT APPLICATION FORM SITE <br /> W fSCL�u���OSAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - MITIGATION <br /> n((�� <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> MAY 1 0 2001 304 E. Weber, Third Floor, Stockton, CA., 95202 FILE coP� <br /> ENVIRONMENT HEALTH (209) 468-3449 <br /> PERMIT/SERVICES 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 /> / ���.(,,y� /� Assessors <br /> WELL Location I/�/2� !T�/�I 1 ss Street CitysT�"�'- ' �l��Zi�p`/ 7-05 Parcel# <br /> PROPERTY Owne�r.Cn.�,/�S /L-I1-,..Qy Ayd3d 3ess � Ci S7 L1 r/1Zip�onen(�/ may <br /> C-57 Contractor Vr�raT��i/�Q�-Z-jl!-L7 Addres` ., g/� ��Ciryp g57r i honed/�Y'6 <br /> Consultant/Sub Contractor-V-76—--76— Address U3 � /` J—City Phone# 7 G <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) I]DESTRUCTION (choose type below) <br /> H SOIL BORING# p OVER-BORE <br /> B WELL# H PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS / 1,W, <br /> Q MONITORING HOLLOW STEM DIA.OF BOREHOLE / ULTIPLE CASINGS?Q YES 1g'NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL B PVC B OTHER: <br /> /91�APOR o MUD ROTARY DEPTH OF GROUT SEAL_' / TREMIE TYPE TO BE USED: flAUGERS HOSE <br /> D AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: 0 Yes WJo (NOTE: MAXIMUM FREE-FALL DEPT IS 30') <br /> B SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: 'Pa- <br /> 0 OTHER:—O OTHER APPROX.BORING DEPTH B: 0 BOLTED TRAFFIC BOX or TOVE PIPE <br /> ,[,, �. 1 CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: Ila S.La�1 �r 1 S /Eb� � I-)� tQd' *��q <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 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signedz u ^ Title/Company <br /> Print Name W 11)l yGrnA _Date r✓- �� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z7 F' (!74� <br /> WORK PLAN DATED: if S ' .tea` <br /> Application Accepted By <br /> Date Issued <br /> Grout Inspection By <br /> Date 2i p2- Final Inspection By e <br /> Z <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: Z <br /> log <br /> ACCOUNTINGONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 2go/ S b S-�a-u► � <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment do 9/27/00 <br /> "6 aof <br />