Laserfiche WebLink
F l.'Dt'2001 12:16 209468 ; <br /> FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLiG HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 —WT <br /> (209) 468-344.9 FILE <br /> NON-fora peDABL pMIT EXPRR s IISSUED <br /> ,rr a Otf"JAIL <br /> Application is hereby made to San Joaquin County tcu a permit In construct and/or install the work described. This appucatbn is made in <br /> Joaquin County Development Title.Chapter 9,1115.3 and.the Standards of San Joaquin County Pubic Health sorvices,Environmental Health Divion.th San <br /> WELL Location 1 y y LI>ww�.pb�c► cross street �,z _cityAssessors <br /> , ZIP Paroew <br /> PROPERTY Owner SI&ATIr SwIr It.. <br /> Address CityZIP fA'At&ZPhone <br /> C-67 Contraetor S AD Q.r L..1/ Address ,ck tWme I Lf- CiIY P LLicrtl 4�V i'honsa - <br /> Consulbmt/9a>sGewlractor(�u <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE paten. <br /> a NEW WELL/BORING(CPT.GEOPROSE.HYDROPUNCH,HAND-AUGER.OTHER-) XbESTRUCTION(choose We below) <br /> Q SOIL BORING V <br /> Q R <br /> []WELL# OVEBORE <br /> 'Other. —rout Speoifieations: RESSURE GROUT <br /> COMMENTS: r_ <br /> r_lrcts ?r„s e�•v� tr. �/���tt:r <br /> TYPE OF WELL IN' ALLATtON TYPE CONSTRUCTION§PECIFICATIONN� <br /> �ANONiTORING HOLLOW STEM Ol BOREHOLE MUk71Pl E T Q YES d NO WELL CASING DIA: <br /> D EXTRACTION Il AIR HAMMER/DRIVE CASING THICKNESS <br /> OF CASING: Q STEEL it PVC Q OTHER: <br /> VAPOR d MUD�PO <br /> DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS a HOSE <br /> a AIR SPARGE 0 PUSGROUT SEAL PU Q Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Ii GROUT SP (CATIONS: <br /> OTHER: ER APP BORING DEPTH a BOLTED TRAFFIC BOX or D STOVE PIPE <br /> ONDUCTOR CASING PROPOSED? (if YES,list specifications here); <br /> 'COMMENTS; <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> GALL THE UNIT IV INSPECTOR 481NORKING 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 Ordln ces, esa Regulations,and all applicable California State Laws. <br /> Signed x Title/Company j./” h/lwWAim �4GAl ljE---A,"✓L <br /> Print Name I Date_ A 25'-f / <br /> METIMINUSE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED:__ <br /> Application A <br /> Date Issued <br /> Grout tnspectlon BY Oats / Final Inspection By <br /> Destruction Inspection By Data ; <br /> COMMENTS/CONDITION . <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEEINFO AMOUNT REMITTED CHECKS RECD BY DATE PERMIT I SERVICE REQUEST p INVOICE <br /> C-57 WC---WAIVER C-57 Letter of Authorization to sign permit En roachment doc 9/27/00 <br />