Laserfiche WebLink
04/24/2001 08:41 20946i1433 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 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 Dewlopment Tille,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health DI <br /> WELL Location�. �/H G D�rI d�" Crass Street Gam!` / Assessor's <br /> oJuen- ��� MQ �_CIty�OL`�'�6yj•I_ ZiPParcel# - OZ <br /> PROPERTY Owner is (-t fs/�7'/�i( CilyJ�/C/�9.2 �IP�S'?�L Pnone# <br /> r <br /> C-57 Contractor m Address <br /> Ci LP��t;rx <br /> consultant/Sub.Cpn`aeo{orC �n..� _ Address6 d e, Gilyr/ewle_. /Uc# Pnone 6-2�e10 <br /> CIS Coordinates:X "!fG_lT_ �--`-,V�q—�S'7-- ,Township //V Range 91 Sectlor /O <br /> WORK TO BE PERFORMED: <br /> ,WNEW WELL)BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) D DESTRUCTION(choose type below) <br /> A SOIL BORING# Z 0 OVER-BORE <br /> Q WELL# <br /> 'Other: p PRESSURE GROUT <br /> Grout Specifiratans: <br /> COMMENTS: <br /> e�ilj /, YO9!!bPI)alc" 6- 6-ROPA10 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?p YES ONO WELLCASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAM MER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL p PVC 0 OTHER: <br /> POR <br /> 0 VAU MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS 0 HOSE <br /> 0AIR SPARGE gFUSH POINT GROUTSEALPUMPED II ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING U HAND AUGER GROUT SPECIFICATIONS,x4t r—caw!! iT hj/sari re/'oL <br /> Il OTHER: n OTHER APPROX BORING DEPTH_E�_0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> *COMMENTS- CONDUCTOR CASING PROPOSED?—(if YES,list specifications here): <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 an/dd Regulations, and all applicable California State Laws. <br /> Signed x--1�lLOClLPF l �o Title/Company fC��[i» (�Ca <br /> Pant Name_(n/ (.t,r('P�rt (iK,C�WGb�iY'�[i.t h Date 4/ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Aacepted By ',` o �V U7u' Dale Issued ,SyJ' l �_€�: ' Area <br /> Grout Inspection By to - mal Inspection 9y T Data <br /> Destruction InspectionJA ate <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMI D CHEgk# REC'D BY DA PERMIT I SERVICE REQUEST# INVOICE <br /> C-57_ WC--WAIVER— C-57 L64t of A th rization to i per it—Encroachment doc 9/27/00 <br /> t � <br />