Laserfiche WebLink
03/13/2001 16:21 20946836 FIFTH FLOOP . PAGE 172 <br /> WELL PERMIT APPLICATION FORM SITE <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 /> (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 Slandards of San Joaquin County P lic He�tSenic es.Environmental Health Division. <br /> timLLAN O.W. Assessor's <br /> WELL Location 1 01 t4• N." L Cross Street LIIf vo Clry_ LA!* .Zip Parcel# <br /> ' 1l, tiRAttJ 4V'r1T - -'i o6 c.. uk y <br /> PROPERTY Owner Zeapon Address.-•O• RAr I1®l0 city� zipu-Iti Phone# 2D q'W6�`3QS� <br /> C-57 Contractor GV-r-irir 1;41AALL1VTl�Add�ress_RSO }�..rL�c, cityMARTc Zip 5S Lid#'S6Y b- phone4fl�•S-'It1-5 5 DD <br /> Consultant/SobContractorH& t-A1-GRaLq Address�it/t/• LAR-FI611-b EZotClty AR 4R Lic# Pnono# 8Ws-8gR-gZ2,y <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPR08E,HYDROPUNCH,HAND-AUGER,OTHER-) t]DESTRUCTION(choose type below) <br /> 0 SOIL BORING# p OVER-BORE <br /> -JPyELL# PRESSURE GROUT rt <br /> `Other, Grout SpedK tions; ort <br /> COMMENTS J'- N yTe, A-, - t 5 NA21, Rd +2AntD f LryAaOIL <br /> TYPE OF WELL TYPE <br /> ,kSTALLATION CONSTRUCTION SPECIFICATIONS <br /> ONITORING — iOLLOW STEM DIA.OF BOREHOLE VV/2-z MULTIPLE CASINGS?D YES XO WELL CASING DIA•?-rc <br /> C EXTRACTION E AIR HAMMER/DRIVEN CASING THICKNESS_, TYPE OF CASING: C STEEL'M�-VC D OTHER; <br /> D VAPOR E MUD ROTARY DEPTH OF GROUT SEAL-- - n ,c TREMIE TYPE TO BE USED: I]AUGERS >105E <br /> 0 AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: p Yes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> O SOIL BORING []HAND AUGER GROUT SPECIFICATIONS: C.t,. Vwit" "o 17!:j- <br /> 1]OTHER: 0 OTHER APPROX.BORING DEPTH E3 q t 1^0OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? N O (if YES,list specifications here); <br /> 'COMMENTS:— --Ifva� <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 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules a�rt`�\ Regulations, and all applicable California State Laws. <br /> Title/Company Si- Qs- a q (�,ST <br /> Pnnl Name �Mk,S U V Iz-1-LS Date 3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: C <br /> Application Accepted By _ ` - Dale Issued 03k I Area <br /> Grout inspection Ei V Date Final Inspection By O Date <br /> Destruction Inspectio y Da <br /> COMMENTS/CONDITION 1.1lr3 <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK R RECD Y I DAT PERMIT/SERVICE REQUEST iF INVOICE <br /> 3 Z V=O= S R# C -) -( S <br /> C-57 WC=WAIVER C-57 Letter of Aukhor a 9n p rrri Encroachment doc 9/27/00 <br />