Laserfiche WebLink
02/13/2001 08:36 2094683433 FIFTH FLOOR NAGE 02 <br /> 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 <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 10 OMStrUCt and/af 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 SeMce%Environmental Health Divislon. <br /> 'Varrwlis' Wr.n.1• u>` <br /> -Z-OSv-w� F.,vj Road"an Se+r-kh \\m" Sw.Y\. *q Assessors <br /> WELL Location s. ,2•'1 mt4a Ewit°b Cross Street City -TCa6 Zlp Parcel# 7-551•13. OL. <br /> :eOJ4 tlwy Sa. <br /> PROPERTY Owner JtSk w:U.i.wrr. r• SY Address P•O' gOX 821 City Vey \ CAZPp 53E15 Phone# <br /> C-S7 Contractor Address City. 7Jp Lic# Phone# <br /> 155 Y j 1, Arc�caa <br /> Consultant/Sub Contiacter cM Inn ti\�L Address °''^A Avtvwb,City 0 fav Lick Phone#rhore.:(5101151-2998x-ADI <br /> u; loonP 17 ceu t01G) Nq-9197- <br /> GIS Coordinates:X .Y ,Township 3 S Range G E Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING(CPT,GEOPROOE,HYDROPUNCH.HAND-AUGER.OTHER-) n DESTRUCTION(ohaase type below) <br /> WgblL BORING# 120/63 U OVER-BORE <br /> U WELL# Q PRESSURE GROUT <br /> *Other; Ho..vC owa¢n 0"I!j Graut Specifications; . <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING U HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?D YES []NO W ELLCASING DIA: <br /> U EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: U STEEL U PVC U OTHER <br /> U VAPOR U MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: U AUGERS U HOSE <br /> U AIR SPARGE UPUSH POINT GROUT SEAL PUMPED; aYes UNo (NOTE; MAXIMUM FREE-FALL DEPTH IS 30') <br /> pf00.BORING aHAND AUGER GROUT SPECIFICATIONS, <br /> U OTHER U OTHER APPROX BORING DEPTH U BOLTEO TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,9st specifications here): <br /> -COMMENTS:�,Lr�9\ •. I •'� .aau1AA c �k <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHM NT 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 Ordinances, Rules and Regulations,and all applicable California State Lam. I <br /> Signed x %I vse �'6A-eltiI,C�'1 TitlelCamPany � Lr f ('"l ver � .Cn �C H Z�-I 1-hAA <br /> Print Name L i S e f Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By �' Oate Issued -f" / r" Mea <br /> Grout Inspecflon gy / !,ti ate Final InsPeclion By i Date <br /> Desbuction Inspection By Da e <br /> COMMENTS/CONDMONS: � <br /> ACCOUNTING ONLY; AID# i-' <br /> PE ES FEE INFO AMOUNT REMITTED CHECK# RECD 6Y DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC_-WAIVER_ C-571 etter of Authorization to sign permit._.._Encroachment clot_ 9/27/00 <br /> Z10 � <br />