Laserfiche WebLink
04/09/2001 07:49 2094683433 FIFTH FLOOR PAGE 04 <br /> WELL PERMIT APPLICATION F�"l� <br /> SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION <br /> 10= 03 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMrr 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 Development Tide,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> �. e# 4 to *tdi mryls2T Assessor's <br /> WELL Location Cross Street ane, City I� Zip Parcel# KA <br /> PROPERTY OwnerlCL,�S h1'5k- l Address Igq(.o CI'IO-(-Ve-C SLI City 5, O�-F-+a l Z1p`ASZ lSPhone# 20 -9y�-*'- <br /> C-57 Contractor�1C C X�)ilddress_��„'P Ja✓C�l �1Y. City L'L"f Zlp J S- Lic#�I�D -Phone#92,5 -'�I -S900 <br /> Consultant/Sub Contractor -r?C Ca(1�� I�GZ17\Address I I5 cSV11(IC��7��'C�Lic# Phone#`�1�0' Sa <br /> CL-- <br /> GIS Coordinates:X -Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ]]NEW W ELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> JI SOIL BORING# 49 10' 1]OVER-BORE <br /> (]WELL# PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING HOLLOW STEM DIA-OF BOREHOLE MULTIPLE CASINGS?fl YES ONO WELL CASING DIA: <br /> 0 EXTRACTION AIR HAMMER/DRIVE 1 CASING THICKNESS TYPE OF CASING: a STEEL D PVC 0 07HER: <br /> a VAPOR ©muc ROTARY DEPTH OF GROUT SEAL TREMIE 1 C=E TO 3E USED: 11 A1.2 CERS 0!-iOSE <br /> 1]AIR SPARGE PUSH PCINT GROUTSEAL PUMPED: p Yes 0 No (N072: MAXI Ui 14i FREE-FALL IDEPTH 15 30') <br /> SOIL BORING 0 HANG AUGE=. GRCUT 3PECIFICA7ICNS: <br /> 0 OTHER:—D OTI-E-; APPROX.SCRING DER-H 11 SCLTED TRAFFIC 5CX or 13TOVE P!Pl- <br /> �[ �l LCONiCU CP,CA 1/N—G?RC/ CScD' (('f'C'3,Asi ec i� cns hera): <br /> *COMMENTS: � (� &AS I )0 4j� (ICJ 1r12 r►CA Ti`s :5±rz '� <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 finances, Rulesand Regulations, and all applicable California State Laws. <br /> Signed x ��RL Title/Company?CA\ef-+f Q-C l 63CZ11a, C��u �•���' <br /> Print Name-�J�CCC� SI��GZ_ ���o " �— Date "A C12- <br /> DEPARTMENT <br /> 12DEPAIRTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: A l�.T`1 <br /> WORK PLAN DATED: n 4 Z- - <br /> Application Accepted By tz U,,��rin L- Date Issued Ll lei/07 Area <br /> Grout Inspection By Date Final Inspection By l/ [ Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: - <br /> ACCOUNTING ONLY: AID# <br /> ., r..INFO Ai jCU?4T MiTi=D C�?cCx# REC'D 3Y <br /> a of c601 .00 o0o3 61 L4 0`- <br /> ;�; <br />