Laserfiche WebLink
04/24/2001 08:41 2094633 FIFTH FLOOR . PAGE 03 <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 t YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to wnstrud and/or install thew Ik 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 4S a "t or Cross StreetL-fn.Co K St CI Assessor's <br /> II _ //—//—�!�,/ _ 7Ns Zip <br /> Sloz Parct:I /37-2 -0/2 <br /> PROPERTY Owner)eltf*� {('tP-na8gcg,./� t(,redress BUJ H/ {ygne/�RV '�/•�/ City _�p_9S2/pz Phonep <br /> C-57 Contractor(TM tt�' Address O e, h City w Z Zip Li b(07 Phone Z.S_ dSM4 <br /> ConsultantlSubEonoatKlorU _ `y>zV�( ��� / <br /> Address�srle� �i6 City PAJ + Uc0 Phone# 2S- f�l�i�Z ryoo <br /> GIS Coordinates:X 74 fw ,y 4z E2. /W/ /r <br /> L.r�s ,Township Range b G Section /a <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> p SOIL BORING S 2 <br /> D <br /> Q WELL p OVER-BORE <br /> *Other:��&A9.621NCH 4 a-ADop"✓ 11 PRESSURE GROUT <br /> COMMENTS: Grout 5pecifintlons: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 'Z' MULTIPLE CASINGS?[]YES 0 NO WELLCASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMERIORIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL n PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS p HOSE <br /> OAIRSPARGE GUSH POINT GROUTSEALPUMPED: nYe•s// ONo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> )'SOIL BORING OHAND AUGER GROUT SPECIFICATIONS: NEaf" C2Mr �S�![t MCCSi.yq--/-/p Q r <br /> a OTHER: n OTHER APPROX.BORING DEPTH « y 0 BOLTED TRAFFIC 80 or 0 STOVE P� <br /> CONDUCTOR CASING PROPOSEO? (if YES,list speclficati(nS here): <br /> 'COMMENTS: <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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin nces, Rules and Regulations, and all applicable CaliforniaStateLaws. <br /> Signedx l� j;-,ZAII <br /> ( • TitWCompany 7/D CGf ,,..ct,a <br /> Print NamPil-ki/2 Date <br /> DEPARTMENT USE ONLY dl <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED' / <br /> Application Accepted By r Issued / Area <br /> Grout Inspection By Date mal Inspection By Data <br /> Destruction Inspector Date <br /> COMMENTS f CONDITIONS: <br /> ACCOUNTINGONLY; AIDS <br /> PE CODES FEEINFO AMOUNTREMITTED CHECKS RECD BY DATE PERMIT/SERVICE REGUESTO INVOICE <br /> C-57_ WC WAIVER_ C-57 Letter of Autho z ion sign permit—Encroachment doc,__ 9/27/00 <br />