Laserfiche WebLink
n,C L� I!`/ D WELL PERMIT APPLICATION FORM SITE <br /> FEB 1 g 2003 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ��// RRONMENTAL HEALTH DIVISION PHS-EHD UNIT IV <br /> ENVIRONMEN 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES <br /> ICES (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 Health Services,Environmental Health Division. <br /> WELL Location L�^ V'00i AJ�� Cross Street LXAL61A S)r"Ci S�pZ Assessors 1_3 <br /> ty Sbo�l�., Zipq Parcel# 11'3 <br /> PROPERTY Owner4OL)Qt'" lopraa TAddress 1&kk �olk City j_v ' Zip9SZ0Z Phone#��'r— <br /> C-57 Ccntracto,&--Qlorr��'Le ,,C tt Address 1'535�,�.>Yt+•P1 AXA+ L CitySc�Zipct5Z12 Lic4A;4llePhone#�3' ZSV-680' <br /> "y, SV•L LIb <br /> Consultant/Sub ContractorClkj`D- (7+Zwy Sw"t^ AgdressL920 61,144ty Quk-11 City-P tAty" Lic# — Phone#525420-&0-7 <br /> 0 1 p r <br /> GIS Coordinates:X 37 5`) 07 P) .Y IZ1 I 52 u Township ItJ Range 6E Section 0 <br /> WORK TO BE PERFORMED: <br /> (1pNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> O SOIL BORING# O OVER-BORE <br /> O W ELL# MW- l b 0 PRESSURE GROUT <br /> 'Other: GROUT SPECIFICATION <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> J MONITORING 9 HOLLOW STEM DIA.OF BOREHOLE 411 MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:?li <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSSc"II ldv TYPE OF CASING: O STEEL ,J PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL D-10' TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: 0 Yes 11 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATION OfIV (4n4^'b <br /> 0 OTHER:_G OTHER APPROX.BORING DEPTH 2-S' N BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? M (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <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, State Laws, and Rules and Regulations of the San Joaquin County. <br /> ' CALL THE UNIT 1 INSP TOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x _G < Title/Company_ PRo�,rb Enu•Rar,c.l-1 Co.•5..11•w; <br /> Print Name 1M01, Date Z/ 16/07 <br /> SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED <br /> D PA TMENT USE ONLY <br /> Application Accepted ByDate Issued A Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'DliIY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC/WAIVER_ C-57 Letter of Authoriz on os n permi _Encroachment doc_ 7/17/00 <br />