Laserfiche WebLink
10!31/2003 17:08 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SI` GATIoN <br /> SAN JOA IN COUNTY EPARTMENT (EHD) UNIT IV ' <br /> ENVIRONMENTAL H LTH D 95202 <br /> 304 'E.Weber, Third 9 4fi8 Stockton, CA., <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE►SSUEDl,cabon is <br /> o San Joaquin County for a permitto construct and/e��stalll County Environmental HealthtDepartmen de in compliance with San <br /> Appilcation is hereby made t Assessoes <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San 4 ZiP -�0' Parcellf I X� ' C)30- 03 <br /> p,��W sr n l SHe� Cross Street F. Clty = <br /> WELL Location 5 5 Zi _L Phone# ' y6. 3' v <br /> Moro r�'vrsM 6rvt ITt clH dyes 509 City sa P�--►— <br /> PROPERTYOwner VII ;FE P-CtC"Lic#" LO!•'Phone�5�11gn: Oc1S.S <br /> G60.j& � L <br /> C-57 ContractorL%%:,. N.xcY.� Address _ Phonear,fit C�g9 6 r <br /> .Z C <br /> Address�� ILJ c .I'Etc`City (� � t-ic#��- <br /> Consultant[Sub Contractor Section <br /> Township Range <br /> GIS Coordinates:X <br /> Y , <br /> WORK O BE PERFORMED: 0 DESTRUCTIO (chooseVER-BOelow) <br /> NEW <br /> ,IV ELI. <br /> G 'GEOPROBE YOROPUNC HAND-AUGER,OTHER') 13pRESSUREGROUT <br /> SOIL BORING e PT Z-V ' I Z S <br /> 0 WELL# Grout Specifications: <br /> •Other. - <br /> COMMENTS: <br /> INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS WELL CASING DIA <br /> :— <br /> TYPE OF WELL DIA.OF BOREHOLE 1�__MULTIPLE CASINGS?0 YES 0 <br /> I]MONITORING Q HOLLOW STEM TYPE OF CASING. <br /> []EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS--G <br /> DEPTH OF GROUT SEALJQ 1 'c1_W4 TREMIE?YPE TO BE USED: (]AUGERS 1tOSE <br /> n VAPOR 0 MUD ROTARY No NOTE:MAXIMUM FREE. FALL DEPTH IS 30'' <br /> PUSH POINT Dii:F.CT PuSii GROUT SEAL PUhIPED:'�`es D � I <br /> n AIR SPARGE <br /> n AIR <br /> PORING p HAND AUGER GROUT SPECIFICATIONS: STOVE PIPE <br /> APPROX.BORING DEPTH T c i q BOLTED TRAFFIC BOX or <br /> n OTHER:, p OTHER if YES.list specifications here): <br /> CONDUCTOR CASING PROPOSED11-��� <br /> 'COMMF.,NTS: r <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS ORENCROACHMENT u REQ NS Ec PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVAN <br /> if that I have prepared this application and that the workiillibe done in Laws. accordance with San Joaquin <br /> 1 hereby cert y p applicable CaliforniaCounty Ordinanc �'RLulll <br /> �Ilu Regulations,and all a pHYoacce Laa►r <br /> Title/Company � �' <br /> Signed x ate_�L,�.�.�03 <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: / <br /> Date Issued ` / � AreaC� <br /> Application Accepted 5 19 <br /> at, Final Inspection By <br /> -.Date__— <br /> Grout Inspection By Date <br /> Desbvcllon Inspection By <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> cert <br /> PE CODES FEE INFO AMOUNT REM(7TED CHECK# REC'D BY DATE PERMIT J SERVICE REQUEST INVOICE <br /> d2 901 �ao 03.E �l� l b� SR# Dv3S �C <br /> 1/2 <br /> -S7 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc` <br />