Laserfiche WebLink
r <br /> WELLPERMIT APPLICATION FGM SITE <br /> RECENEDMITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> DEC 2 4 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIROWENT HEALTH (209) 468-3449 <br /> PERMIT/SERVICES . - <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED application is made In compliance with San <br /> Application is hereby made to San Joaquin County for a permit to construct San J install the work described. This app Assessor's <br /> Health <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> U5 City 1 V-O. Zip . Parcel# <br /> WELL Location UJ' Cross Street <br /> �0- --b uJ. �� +"� ; Cityrll Zip�S'a:'�Phone# .�3 --q�3� <br /> PROPERTY.Owner�J _Address ��� =+ <br /> Z�i5 <br /> S L� final, Address 3E 5 k4.r!`'S Ca City vbl �ZiP4�n'Lic# '63Phone# <br /> C-57 Contractor 1� ( �k oj.l$6 Lic# Phone# S�+�Zl <br /> AT- (, Aw. Address <br /> Consultant I Sub Contractor [117+ bo.,_L a ` City <br /> Section <br /> Y ,Township <br /> Range <br /> GIS'Coordinates:X <br /> W RK TO BE PERFORMED: 0 DESTRUCTION(choose type below) <br /> NEW WELL 1 BORING(CPT,GEOPROBE,HYDROPUIJH,HAND-AUGER,OTHER') OVER BORE <br /> 'SOIL BORING# € PRESSURE GROUT <br /> 0 WELL# Grout Specifications: <br /> .other; <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPEC ON CASINGS?a YES )kNO WELL CASING DIA: _ <br /> []MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE <br /> ubY TYPE OF CASING: a STEEL ©PVC j]OTHER:' <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS— AUGERS []HOSE <br /> a VAPOR VUSH <br /> ROTARY DEPTH OF GROUT SEAL L5 TREMIE TYPE TO BE USED. QPOINT GROUT SEAL PUMPED: 0 Ye��(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> U AER SPARGE HAND AUGER GROUT SPECIFICATIONS: <br /> kOIL BORING a <br /> OX.BORING DEPTH I5 <br /> BOLTED TRAFFIC BOX or U STOVE PIPE <br /> U;OTHER:� []OTHERS APPR <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORING'S REQUIRE ACCESS OR ENCROACHMENT DINSPECTIONS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Ru es and Regulations, and all applicable California State Laws. <br /> HH-- �4r�o�tn�s <br /> ��_ TitielCompany A e <br /> Signed x � <br /> � D�+{uf tl,v►. {�'1 Date - <br /> PrintName DEPARTMENT USE�°ONLY t ` <br /> J <br /> SITE MAP IN UNIT IV FILE,ADDRESS: r L4,i <br /> WORK PLAN DATED: 7-0 1 42 1 <br /> Date Issued Z Area ti <br /> Application Accepted ByDate" 4' <br /> Date U 2—Final Inspection By <br /> :Grout Inspection By <br /> Destruction Inspection By Date <br /> it <br /> ;COMMENTS I CONDITIONS: <br /> i, ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 15ERV10E REflUEST# INVOICE <br /> .oa S� y O 3 <br /> 3 So 9/27/00 <br />{ C-57 WC -WAIVER <br /> C-57 Letter of Authorization to"sign permit Encroachment doc <br />