Laserfiche WebLink
11/13/2003 16 23 2094683433 FIFTH FLOOR PAGE 03 <br /> WELL PERMIT APPLICATION FORM SITE <br /> • MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATIONT(GAA <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 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 /> 91=11on Is hereby Ma4e to San Joaquin County for a permit to oxmitruct and/or install the work described This application Is made 1n compliance with San <br /> aquin Coun velop enl Title Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services Emnronmental Health Division <br /> r�,, Assessor's q <br /> 3LL Location �1/I I� �G Cross Street _le' City .S'�?�Ck V VZip d Parcel# <br /> tOPERTYOwner CW��1j� �a <br /> Address��D 1 �,i�I,+ltJ[[r/l C. p 10 PhDne# l ��3 <br /> 57 ContactorYI Address - City zipa �'�+cPhone <br /> insultant/SubGantrector Addre5s7tl1�T City GUt Phoneik <br /> S Coordinates X �Z � Y rl X312 ,Township Range SecLan <br /> ORK TO B£PERFORMED <br /> NEW WELL I BORING(CPT,GEOPROBE HYDROPUNCH HAND-AUGER OTHER-) a DESTRUCTION(choose type below) <br /> a SOIL BORING# [1 OVER-BORE <br /> []WELL s [1 PRESSURE GROUT <br /> 4har Grout Specifications <br /> 3MMENTS <br />'PE OF Wr;LL INSTALLATIQN TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 11 HOLLOW STEM DIA OF BOREHOLE_MULTIPLE CASINGS?11 YES YNO WELL CASING DIA O' <br /> E3GWWkC'nON AIR HAMMER/DRIVEN CASING THICKNESS TYPEF0 CASING [I STEEL PVC a OTHER <br /> APUD ROTARY DEPTH OF GROUT SEAL r I I MIE TYPE TO GE USED [[AUGERS n HOSE <br /> Alit aPARGE it PUSH POINT GROUT SEAL PUMPED Yes p NoXI <br /> _ (NOTE: MAXIMUM FREE-FALL DEPTH IS 30'} <br /> SOIL BORING p BAND AUGER GROUT SPECIFICATIO <br /> OTHER OTHER APPROX.BORING DEPTH� I S )e80LTED TPAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSiwDT Q (' YES list specifications hers) <br /> ONIMENTS <br /> _ 1 <br /> OTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify that 1 have prepared this application and that the workwill be done in accordance with San Joaquin <br /> ounty Ordinances, Rules and Regulations, and all applicable California State Laws. Lir J <br />+grx;C x <br /> T+Ue/Company, S ,04 I r )rit <br /> kit not Name 1 Date (1 D3 <br /> DEPARTMENT USE ONLY <br /> ITE MAP IN UNIT IV FILE,ADDRESS: <br /> IORK PLAN DATED: <br /> pplicabon Accepted By f _ _Date tired /I/ a `T9 <br /> toot inspection By Date Fnal Inspection By Date <br /> estirucbon Inspection 22 Dale <br /> 05111111114S I cc DMONS <br />�...OUNTING ONLY; AIDS �ar� <br /> PE CODES FEE INFO AMOUxT REmrrMo CHECK# RECD BY PATE PERMrr l SERVICE REQUEST 0 INVOICE <br />:-57 WC­:-WAIVER— C-57 Letter of Authorization to sign permit_�Encroachment doc 4/27/00 <br />