Laserfiche WebLink
11/13/2003 10: 58 209468343_ FIFTH FLOOD. PAGE 02 <br /> WELL PERMIT APPLICATION FORM <br /> hov 2 Y SAN JOAQUIN COUNTY - r MIT400*1014 <br /> ENVIRONMENTAL. HEALTH DEPARTMENT ( �t� 2 NIT IV <br /> „`1VrHEA 304 E.Weber, Third Floor, Stockton, CA., 95 02 <br /> '%-,ERVICFS (209)488-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Appticatlon is hereby made tc San Joaquin County for a permit to oonstn.d and/or install the work descnbad. This application iS made In compliance with San <br /> Joaquin County Development Title,Chapter 9.1115.3 and the Stwdards cf San Joaquin County Environmental Hoaio Dapartment. <br /> /AVAra _ y 7 Assess <br /> or's <br /> WELL Locati5 stroet*ilfi4trtd/ Zip ParcelC <br /> PROPERTY 0,,.r.51/ CItyS/ t / ISS b <br /> k ziP Phone l� <br /> C57 Contrac:nr fCAT l% _AddresZ%T I�l� uu, City �'�+z;p _L+rte prones 20t-A5 7/2 <br /> COnsUltant/Sub 1ContraetorC�N,pFGu&vjSN/t • Address/'I(W 14dr14tyIN C; ltilli Gym U0 Ph orJ#�'7C'�'�512 <br /> GIS Coordinates:X ,Y ,Tcwnship Range SeUoon <br /> WORK To BE PERFORMED. <br /> 0 NEW WELL/130RING(CPT.GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER') STRUCTION(chp6se type Celow) <br /> D SOIL BORING# VER-BORE <br /> 0 WELL# 13 PRESSURE GROJT <br /> ^Other. Grout SpoClficatk": <br /> COMMENTS:D0fl chmarf 7 wdlbs DUt nil i i Lym.wt 60 jiL " t7Cia_i_1 P"It T'D fir stlef ce <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPFCIF1CLkjIQNS <br /> 13 MONITORING G HOLLOW STEM DIA.OF BORP-HOLE MULTIPLE CASINGS?Q YES ONO WELL CASING DIA <br /> 0 EXTRACTION 0 AIR HAMMERiORIVEN CASING THICKNESS _TYPE OF CASING: 0 STEEL [IPVC q OTHER: <br /> 0 VAPOR 1]MUD ROTARY DEPTH OF GROUT SEAL TREMIC TYPE TO IRE USED: Q AUGERS a HOSE <br /> 13 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Q Yes I]Nc (NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br /> p SOIL BORING Q I,-AND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH a SOLIED TP.AFF:C BOX or 0 STOVE Pl?E <br /> CONDUCTOR CASING PROPOSED? (if YES,list specif.ations here): <br /> 'COMMENTS: - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKIN13 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I herebycorti! that I have spared this application and that the work will be done in accordance with San Joaquin <br /> County s a nd Regulations, and all applicable California State Laws. <br /> 5i9ne x Tate/Compony in C C:' <br /> Print Name `_ l Date <br /> 03 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED). U, f `� <br /> App lcntion Accepted By�i Oate Issued -7 e— <br /> Grein Inspection By Date Final Inspection By DEQ• <br /> Destruction Inspection By !�k Date ! Z Z 2_.! <br /> a <br /> COMMENTSlCONDMONS: CUns� <br /> l ACCOUNTING ONLY AiD# serve <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST C INVOICE <br /> C-S7� WCC WAIVED_ C-57 Letter of Authorization to sign permit Encroachraerrt doc_ 1/25f <br />