Laserfiche WebLink
09/25/2001 07:44 20946B3� FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SE VICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 5202 <br /> (209) 468-3449 <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 and the Standards of San Joaquin County Public Heall Services,Environmental Health Division. <br /> 'ti-VIIIA Assessor's <br /> WELL Location Gross street_ No City ZipgSI�Z.3I Paroel# <br /> PROPERTY OwnerA�t ,Tt,v1-n trVti WC Address '7I 17 S• t1>.1� Cil yr ZiP qT2}I Phone#2.DQ-g8Z'S`irr5 <br /> C-57 Contractor 1,,-6 l� NV1,�1ti Addresssj� 1'Ia�sS�. �-� -city,MAL�t <br /> A _Zip `15S Lic#�1i`1� Pnonett 1'2-5-)'1 3'�1� <br /> Consultant/Sub Contractor- /lVl ( l�1-DRAUA Address3 VII' I.alrr1(J Ila�l 5�'� 1Z-V <br /> Clry Lief 4y1'L_ PhoneN$t7S'QJgq-AZ�.� <br /> GIS Coordinates;X ,Y Township Range Section <br /> WORK 70 BE PERFO MED: <br /> NEW WELL BORI (CPT,GEOPROBE,QDROPU HAND-AUGER,OTHER-) a DESTRUCTION(choose type below) <br /> 'SOIL BORING 0 OVER-BORE <br /> 0 WELL# 1, B PRESURE GROUT <br /> .l , <br /> 'Other: Grout Speclllcallons: n r l lr!a r� <br /> COMMENTS: hill <br /> TYPE OF WELL <br /> INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF RORFHOLE .911 <br /> rl MULTIPLE CASIN S7 U YES ONO W ELL CASING DIA:_ <br /> a EXTRACTION 1AIR HAMMERfE12QCASING THICKNESS TYPE OFCASING: 0 STEEL U PVC n OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL _TREM14 TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> U AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: U Yes 0 No (NOTE: AXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> U OTHER: 0 OTHER APPROX,BORING DEPTH vr7 ',,b OLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPTOSED? (If ES.Ilslspecl0ratlons here): <br /> *COMMENTS: ✓•^ }/I v1 $ ITL ' `I-;.-.— <br /> I., 1 � -• N NTS <br /> NOTE: OFFSITE BORINGS 0EQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR LL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be don in accordance With San Joaquin <br /> County Ordin ces, Rules and Re ulationsil,��antd all applicable California State La s. <br /> Signedx F'"' V TtlelCompan>fjF.• �..63� T (sWleYeit Nm.�y < At, Vi� <br /> Print Name YiL ate "�. "tel <br /> EPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: / n/ <br /> Application Accepled By ale Issued d� t� 1 Area <br /> Grout Inspection By Date final Inspection By Date <br /> Destru:tion Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# O <br /> E 'D BY I DATE PE MIT f SE ICER OUEST# INVOICE <br /> C-57_ WC=WAIVER_ C-57 Letter of AlithooilzotiV sign permit_Encroachment doc_ 9/27/00 <br />