Laserfiche WebLink
WELL EMT APPLICATION FC Vi l SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> n (a r�- ENVIRONMENTAL HEALTH DIVISION (PHS -EHD) <br /> N \� Eff 1I' I ' ' ll 304 E . Weber, Third Moor, Stockton , CA. , 95202 <br /> APR 2. 8 <br /> 2004 (209) 468 -3449 FILE COPY <br /> !� NON -REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ <br /> >pplicatic9 la`herebIyijT"AJ aWl Auin County for a permit to construct and/or Install the work descrihed . This application is made in compliance with San - <br /> Joaquin Courtty_ RVgq;g MljCj Dhapter 9-1115 .3 and the Standards of San Joaquin County Public Health Services, Environmental Healt Division. _- <br /> WELL Location I1S3TO L.J . I:/62N7 MICE RD Cross Street Zip Parcel# <br /> 4 . <br /> PROPERTY Owner eIESTAE�- PFo/Et7l(5ff Address 1060 l'.�1 Nwy 17- City 40 '/ Zip9 _a 2 Phone# 369 / o SI ! <br /> C-57 Contractors deE CC' Address 9Sc7 HOr4)C Z1 CItyMAA7r✓E ZZIp3,>_�.�ic# Pnone# 9zS 3/3 S�oa <br /> Consultant / Sub Contractor 4TC ASSoC /A >ES Address // ( 7 Lode- PA� � City M ��Et? Licd Phone# S773-I <br /> 7 Y p - Range Section GIS Coordinates: X , Township <br /> j WORK TO BE PERFORMED: 0 DESTRUCTION (choose type beloy) <br /> NEW W ELL �G GEOPROBE, HYDROPUNCH , HAND-AUGER, OTHER') 0 OVER-BORE <br /> "SOIL BORING # 3 Bw4 •Nrt 0 PRESSURE GROUT <br /> 'Other: W ELL # Grout Specifications: <br /> COMMENTS SCG kJo4e P4A � 0a.< S9111190-fir" cE /I ✓Esi � 790^+ i9tor <br /> o3 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICA71ONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE tZ 1 r MULTIPLE CASINGS? o YES 0 NO WELL CASING DIA:_ <br /> 0 EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL I7 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE : MAXIMUM FREE-FALL DEPTH IS 30 ') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: IXOTHER D LAIC- T APPROX. BORING DEPTH ^' /OO 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> RV LN 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 with San Joaquin <br /> County Ordinances , ules and R lations, and all applicable California State Laws. <br /> Signed x co TitlelCompany Ar � 7G �soer� 7� <br /> _Dateya :4 <br /> Print Name �� �� DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED : <br /> nye � � Date Issued Area D � <br /> Application Accepted By " ' `� ' Date 23 b <br /> Grout Inspection By. Date Final Inspection B <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: NINE <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK11 REC'D BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> C- 57_ WC -WAIVER. C-57 Letter of Authorization to sign permit_ Encroachm = 9 /27/00 <br />