Laserfiche WebLink
FIFTH FLOOR , <br /> PAGE nz <br /> 02/13/2001 08:36 2094683433 <br /> ....' Q <br /> WELL PERMIT APPLICATION FORM , SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468.3449 <br /> NON•REFUNDAB E PERMIT EXPIRES 1 YEAR FROM DATE ISSUEO <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, pier,9-1119,2 and the 6 rds of San Joaquin ODunty Public Health Services,Environmental Health Division. <br /> 0 Assessors <br /> WELL Location " S /ntreat Lam'" City ZIP Parcel# <br /> PROPERTY Owner ('.A1.,'(Qd.IS QAC d ss r•�• Zti�� City 7'� Toa Zip9S10 LPhme# <br /> CS/Contraccor1,r o L". /�—, c�L (�tldress ���% i 'N: C Cityflkt- NL2iP }Lich +yb Phone# <br /> Conwltand/Sub Contractor l-F('2 rrtLL Address IS"S Gera$ A,rE. City pa,�c�itnlA ucq Phone# 53D 251 285$ XZtO <br /> GIS Coordinates:X ,y_.TownshipRange _ SBGion <br /> WORK TO BE PE FORM DESTRUCTION(choose type below) <br /> EW WELL/BORING CPT GEOPROBE,HYDROPUNCH,HAND-AUGER OTHER') 0 <br /> D SOIL BORING# 0 OVER-BORE <br /> D WEU.# D PRESSURE GROUT <br /> Grout Specifications: <br /> COMMENTS: <br /> I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ' <br /> D MONITORING D HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?D YES D NO WELL CASING DIA: <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER <br /> i D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL 7REMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE D PUSH POINT GROUT SEAL PUMPED:- ,Yes ]]No (NOTE; MAXIMUM FREE-FALL DEPTH IS 30') <br /> /VOa.BORING D HAND AUG��E..R((}}�� GROUT SPECIFICATIONS: <br /> D OTHER: RA7HER — APPROX.BORING DIM �� D B0L7E0 TRAFF C BOX or D STOVE PIPE <br /> { r CONDUCTOR CASING PROPOSED? /'10 (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 c rtify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Oomgncen� Ind R ulations,and all applicable California/State Laws. <br /> [i Signed xl/ (l,1jJ/�-�-�—� ,�jj Q litle/CompanY <br /> I Print Name /�l'YL� Alt-/CdlQ Date <br /> DEPARTMENT USE ONLY o <br /> J SITE MAP IN UNIT IV FILE,ADDRESS: Hu FI <br /> WORK PLAN DATED:(� /1 f O Uj� LI�lG Jo h <br /> Applicalion Accepted Byy_l._o ` \l ' ` t•� Oate Issued\ j C=1 I,. lVea <br /> Grout Inspection By Date /- Final Inspection By Date' <br /> Destruction Inspection BY �- Date ` X I w a. 65 VW 0111913 <br /> COMMENTS/CONDITIONS <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REG-DRY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57 WC_-WAIVER_ C-57 Letter of Authorization to sign permit—Encroachment doc_ 9/27/00 <br />