Laserfiche WebLink
. Is <br /> ID <br /> WELL PERMIT APPLICATION FORM <br /> } SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> u ° 2003 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> M(ay ENj�EPti`�H 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ��� R ACES (209) 468-3449 O f1IF <br /> Joaqukpplicin <br /> �ounty De velop a to San Joaquin CouOnry fora permit to constr;cctt aIX/or install Fe or29 1 1 11 YEAR kdes r bed.ISSUEDOM DATE This applicatlon is made In comlplLi�ance)wi San <br /> Joaquin County Devebpment T1Ue,Chapter 9.1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> NELL Location\L{'-� S , \xw 3 3 Cross Street DU r �� Assessor's <br /> \ Ity."ft2c. \S_9yi.. �p°�531 b Parce��_- <br /> PROPERTY Owner�\ve;s \ J Or�S gddress3 1A� }� 33 q <br /> �w _CityT 2! � Zip IS31b Phone# <br /> CS7 Contractor a� �2.a\\ U­ <br /> Address Q� �o.� % Gry.`=s",,�to—zi olIS-I,y—)U�Z ", G�— <br /> Consul t/Sub Contractor-G-'A fl �� Phone# 1 7-I 4'I D p <br /> ---_ -°l r �' �rh Address_ t�dl 1�� S'� Clryll 1�1pl.FJ Lic# <br /> GIS Coordinates:X <br /> Y Township_RangeSection <br /> WORK TO BE PERFORMED- <br /> U NEW W ELL f BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) <br /> 0 SOIL BORING# 1]DESTRUCTION(choose type below) <br /> 'Other. <br /> WELL9OVER-BORE <br /> - 14-O-L. Vv Jr 0 PRESSURE GROUT <br /> COMMENTS a- Grout Speclfrcations: <br /> TYPE OF WELL INSTAL ATION TYPE CONSTRUCTr <br /> ON SPECIFICATIONS <br /> MONITORING &HOLLOWSTEM DIA.OF BOREHOLE Z" <br /> 0 EXTRACTION MULTIPLE CASINGS?DYES ONO WELL CASING DIA: <br /> p AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL A PVC <br /> 0 VAPOR - 0 MUD ROTARY DEPTH OF GROUT SEAL D OTHER: <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: E TWE TO USED:. p AUGERS p HOSE <br /> 0 SOIL BORING 0 HAND AUGER D Yes 0 No (NOTE: <br /> TE:: MAXIMUMM FREE-FALL DEPTH IS 3D') <br /> GROUT SPECIFICATIONS: <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH <br /> _ J BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> p <br /> -Z W��CONDUCTOR CASING PROPOSED? (If YES,list specifications here): <br /> *COMMENTS:— <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 withh San Joaquin <br /> County CkVe , R e Regulations,and all applicable California <br /> /State <br /> lLaws. P�kho"I-A-d. 0'- dU_�_Da�lin <br /> Signed x (') - Tltle/Company. �e,Jl Ds� c rz Q (�.� - cs �6 )'xj <br /> PnntName CZG� V1J� g blarL.� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: // 0;/D'Z - <br /> Application Accepted By /Vt�cC ,e..�/c,-sr� Date Issued �27 q,ga /yS3 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AIL#. <br /> PE CODES FEE INFO AITTED CHECK# REC'D BY DATE PERMIT I SERVICE RE4UEST# INVOICE <br /> 350 i ,+t LJ D l�So7 CUTA ay.. e3 003+370 <br /> C-57 ✓ WCC WAIVER_ C-57 etter of Authorization to sign permit ✓ Encroachment dock 9/27/00 <br /> c E �a �J75 4, 2?"r,j <br /> ED 3�dd aoo�� Hl�r� <br /> EEbE89b60Z 99:EI 100Z/BZ/Z0 <br />