Laserfiche WebLink
12/08/2000 09: 57 2094683439 FIFTH FLOOR PAGE 03 <br /> 6 2094683433 0 <br /> WELL PERMIT APPLICATION FORM &TE <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 /> D (209) 468-3449 <br /> JAN - 4 2001 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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.Chapter 9-1115.3 nd the Standards of San Joaquin County Public <br /> Health Services,Environmental Health Division. <br /> �A..f/x,� /T tY tLbL � PaS�o� Assessor's _n3 <br /> WELL Lacatlo `T� Cross Stre1e+t jr�/.�KUG�71w. Ci ZI Parcel#It�1't� <br /> PROPERTY Owns Addddrreess I.R C71'1 1 ft City fk-NDA 7-ip Phone#gig-fA <br /> 70 IalatU <br /> C-57 Contracto Addrewgso kcpm- t <br /> i��y �4f Mzip Lig#—Wi(P-S � <br /> Phone 44AR--!&O <br /> Consultant/Sub Contractor t Address`xig- tI� PViC�'f�ity4f Lic# Phon A5 - Q <br /> GIS Coordinates:X ,Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> rNEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER•) D DESTRUCTION(choose type below) <br /> n SOIL BORING# 'S D OVER-BORE <br /> D WELL# D PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE t_�_MULTIPLE CASINGS?BYES YNO WELL CASING DIA: <br /> \rn EXTRACTION D AIR HAMMER/ORIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER: <br /> O VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE D PUSH POINT GROUTSEAL PUMPED: D Yes o (NOTE: MAXIMUM FRE •FALL DEPTH IS 30) <br /> SOIL BORING DHAND AUGER GROUT SPECIFICATIONS:�F_c-rl 1ZF"t�I�trEC<S� <br /> OTHER: OTHER APPROK BORING DEPTH a <br /> D S T D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,lis/l/specifications hers): <br /> -COMMENTS: �� --�{ 042 614 i�r ( S I iSN� �17fLC_�r' <br /> 7 t-VL4- <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 hire erti t have prepared this application and that the work will be done in accordance with San Joaquin <br /> Court na s, ules and Regulations,and all applicable California State L WS. <br /> Signed z �,T� Title/Company �,1 <br /> Print Name .b Kr Date lu1 w <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> ,,Application Accepted By 7 Date Issued tik1 4 Area <br /> Grout Inspection By Final Inspectio e By Date <br /> Destruction Inspection By Date _„ <br /> ll" <br /> COMMENTS/CONDRIONS= .(?lWl <br /> ✓ < i,5 ISS•6� "l10 o/'� rr (IZ ow <br /> ACCOUNTING ONLY: AID# FAnt <br /> PE CODES FEEINFO AMOUNTREMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> O 8 9 60 3 'Z s fjf/ L'(' Z <br /> C-57_ WC=WAIVER_ C-57 Letter of Autho z ` n. si n permit,_Encroachment doc_ 9/27/00 <br />