Laserfiche WebLink
09/13/2@01 18:25 2894683433 FIFTH FLOOR PAGE 82 <br /> Ld <br /> WELL PERMIT APPLICATION FO M SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SE VICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS- HD) UNIT 1V <br /> ' 304 E. Weber, Third Floor, Stockton, CA., 9202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE l SUED <br /> Application is hereby made to San Joaquin County for a pemvt to construct and/or Install the work descrlbed, hls appllcabon is made'in compliance with San <br /> Joaquin County Development Tale,Chapter 9-1115.3 and the Standards of Sara Joaquin County Public Health Services.Environmental Health ;vision. <br /> WELL Lacatlon-Ng 14arnne hee LanCross Street W L4ne ftznWc; Assessors - o <br /> city Eac b zip952/0 Parcel# <br /> PROPERTY Owner r0g0 markeli (0- :2m��'IleeAddress 2006 COw L-dAyah ft4re 51C ocity A kathm Zip 583 Phc..19 <br /> I <br /> Com/Contractor Lbcillina. Address 100 (4M 3r} City�s l ip? Zip Lic#?24%yi Phone# 2/6--}1-yibn <br /> Consultant/Sub Contractor �awtbr;a_ nvl&rl=w Address 6262 liell►s city me rl L;c# Phonex SIo -ySD- Ig$S <br /> GIS Coordinates:X Y Township Range Section <br /> W41 ovjw: 3P O;I Co�►� ,-Safi Mari 2`t5"sW Yl s�st,3k�13,`r`—s�P-e.%itb I{lA mg-s- (T2s 251-0&n <br /> W RK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGEP..OTHER-) 11 DESTRUCTION(choose type below) <br /> Q SOIL BORING# 1]OVER-BORE <br /> :WELL#Mkt- I �{aU* rota/-9 Q PRESSURE GROUT <br /> "Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL. INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE 3p`—�L�MULTIPLE CASING ?Q YES 'VNO WELL CASING DIA: - F 1-x,q ' <br /> aEKrRACTION . <br /> AIR HAMMEWDRIVEN CASING THICKNESS 5,Y4k''ID TYPE OF CAS3 G: 0 STEEL XPVC a OTHER: <br /> 3 VAPOR _q MUD ROTARY DEPTH OF GROUT SEAL S -S� TREMIE PE TO SE USED: :Q AUGERSHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Yes 0 No (NOTE: AXIMUM FREE-FALL DEPTH IS 30') <br /> [I SOIL BORING p HAND AUGEP. GROUT SPECIFICATIONS: <br /> d OTHER: []OTHER APPROX,BORING DEPTH 10 / 1�13LTED TRAFFIC SOX or []STOVE PIPE <br /> CONDUCTdR CASING PROPOSED? 'l (ifY ES.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 FORA L REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be don in accordance with Saiz Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Vgned,x+ Trtle/Company �'�+�'► �'" �nq <br /> Print Name 54m, t <br /> D to l t p <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: p <br /> Application Accepted gy <br /> Date Issued till Area O <br /> Grout Inspection By Date Final Inspection By Date / 3 OZ <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK RECp 13Y DA7E PE MITI SERVICE REQtlEST s INVOICE <br /> yor� l4! a's Id <br /> C-57 WC._-WAIVER C-57 Letter of Authorization to sign permit rncrocchment doc 9/27!00 <br /> i <br /> 1 <br />