Laserfiche WebLink
�. FILE COPY,,. <br /> WELL PERMIT APPLICATION FORMSITE <br /> � <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> SEP 2 0 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> fl, �j-H 304 E. Weber, Third Floor, Stockton, CA., 95202 f <br /> (209) 468-3449 <br /> NON-REFLINDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED v <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the wait described. This application is made in compliance with San <br /> Joaquin County Development <br /> Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> WELL Locatton�;S_( �+>~ �P+lo t Cross Street �i/a7 C' �a Assessors <br /> -rl �y / Zip <br /> gS 7 Pard# 8� ,2� z� I <br /> PROPERTY Owner�I9N7D>�e I & _ Address"_ Zip W/Z Phone# /d <br /> C-67 Contractor , ,�'L'Al+e res -0, 3.J6 city aG)k zio17VS7/uc#7I:b7fPhone#_X737V 9dC <br /> Consultant/Snb 6entrWorn -FAO- Address dC, E"Q •ICit}+�Aw6c#SafV Phone# 695;P S <br /> GIS Coordinates:X Y Township 2 N Range ee�4' Section .Z/ <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) �tESTRUCTION(choose type below) <br /> p SOIL BORING# p OVER-BORE <br /> 0 WELL# I PRESSURE GROUT <br /> •Other. -Grout Specifications: 3 A4Amk llarf�.y/L S Y-Q�g�A <br /> COMMENTS: <br /> i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ! <br /> p MONITORING p HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?p YES p NO WELL CASING DIA: ' <br /> i <br /> p EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: p STEEL d PVC p OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS 1]HOSE <br /> p AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 13 HAND AUGER GROUT SPECIFICATIONS: f <br /> p OTHER: D OTHER APPROX BORING DEPTH 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list speascations 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 Ons and Regulations,and all applicable California State Laws. / <br /> f/•ud G,d�,��,1,,J GC J�'cs"' <br /> TMdCorrWnY <br /> Signed x -Gam. <br /> Print Narne P G Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued <br /> Grout Inspection Byfl <br /> Date Final Inspection By ' e <br /> Destruction Inspection By Date <br /> COMMENTS f CONDITIONS: <br /> I ' <br /> ACCOUNTING ONLY: AID# � <br /> PE CODES FEE INFO AMOUNT REMITTED T; IZZRMrr/SE RVICE REQUEST# INVOICE <br /> bZ r_;i7 Wr -WATVFD r-;i7 I atter,of, AI1tl+nri7A#inn fin Ginn nornnit Fnrrnnrhmont rinr Q�97lf1f1 <br />