Laserfiche WebLink
WELL PERMIT APPLICATION RM SITE <br /> MITIGATION <br /> FILE COPT ENV RONME TAL HEALTH DNISIUN-(PHSREHD)N JOAQUIN COUNTY PUBLIC HEALTH SES [r IT �V <br /> - <br /> . <br /> 304 E. Weber, Third Fioar, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> TION-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r <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 /> il � 95'3 <br /> Assessor's <br /> WELL Location Cross Streeiit R; Cityi Parcel# <br /> PROPERTY Owner Q,"- <br /> �. Address&a[D1 %6V � I�Citys �otr� Zip 9q� Phone# ZS- x�mF I <br /> C-57 Contractor e__ eA' k Address 3fo3Z C)r, X3 8. CitylRgr�tor�e ip 7�Z.Lica_71-7510 Phone#_�y <br /> Consultant/Sub Contractor SECn?L� Address �C+� fe A!bb Cityl.w"Q;&A-ic# Phoned <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> a NEW WELL!BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) i (]DESTRUCTION(choose type below) <br /> 1)SOIL BORING# 11 OVER-BORE <br /> HELL# p PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: 1 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS rI <br /> _ONITORING OLLOW STEM DIA.OF BOREHOLE Sir MULTIPLE CASINGS?(I YIZ�NO WELLCASING DIA: Z <br /> 0 EXTRACTION ©Al HAMMER/DRIVEN CASING THICKNESS S b TYPE OF CASING: q S`TEELL VC []OTHER: <br /> Q VAPOR p MUD ROTARY DEPTH OF GROUT SEAL G 7 ii TREMIE TYPE TO BE US-E-- <br /> D. GAUGERS []HOSE '. <br /> p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: s p Ido (NOTE. MAXIMUM FREE-FALL DEPTH IS 30') <br /> l]SOIL BORING I]HAND AUGER GROUT SPECIFICATIONS: 1\E!� CP_P�� <br /> p OTHER: __[JOTHER APPROX.BORING DEPTH OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> i' <br /> CONDUCTOR CASING PROPOSED?moi)(if YES,list specifications here): <br /> 'COMMENTS: } <br /> i.. <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 <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 and Regulations, and all applicable California State Laws. <br /> iI� <br /> Signed x � Titte/Company <br /> PrintName +�*] SSS I Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADD ESS: G <br /> l <br /> WORK PLAN DATED:. <br /> I <br /> Application Accepted By Date Issued 1� Area <br /> , <br /> Grout Inspection By 0.P^ Sv?'.I <br /> Date 0 Fnai InsE1lIpection By Date <br /> Destruction Inspectlon By Date �1 � <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FA <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECM BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> C-571-- WC -WAVER C-57 Letter of Authorization to sign PSerrttit Encroachment doc 9/27/00 <br /> E0 39Cd a00-13 H1-:11-1 EEVC89V60Z 1c:ET 000Z/t,0/7-1 <br /> I � <br />