Laserfiche WebLink
P2/02/2001 09:27 209(' 9433 FIFTH FLOOF PAGE 04 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 469-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 4pplication 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 9-11153 and the Standards of San Joaquin County Public Health Services,Environmental Hellr SDivision. <br /> AssesWELL Location u' I �L0 Pt Wl"4 Cross Street�x City �, T c" Zip Parcel# <br /> c + I r� 5 Address City Zlp Phone# <br /> PROPERTY Owner _ r �37 gS 7 5 <br /> C r9�c�- �;j,,3�7 / �l a <br /> C-57 Contractor c'S' `�`, /i� i Address 9 o o S SII�� S{. City Zip Llc# Ph. <br /> ne# <br /> Consultant/Sub Contractor <br /> �i ry Address �}3 /V,M.rlrc fi S n j City <br /> �� }/c Q: 8�> Township Range Section <br /> GIS Coordinates' > /7. r ?� <br /> WORK TO BE PERFORMED: �— <br /> '*NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> 0 SOIL BORING# a OVER-BORE <br /> WELL# a PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: /V 3-7 r 4 SC' ' a t ° j c, 5'1 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE<,;) '* MULTIPLE CASINGS?[]YES ONO WELL CASING DIA:__ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS <-2 TYPE OF CASING: 0 STEEL n PVC 1]OTHER: <br /> O VAPOR a MUD ROTARY DEPTH OF GROUT SEAL____:�c f7� TREMIE TYPE TO BE USED: 0 AUGERS �HOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes #,No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 1]HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> o OTHER: 0 OTHER APPROX.BORING DEPTH_ <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: <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 Ordinances,Rules and Regulations, and all applicable California State Laws. <br /> Title/Com an - <br /> Signedx �� �tro �-� 5 .it ;I P Y <br /> 01 <br /> Date s o 4.1-1 <br /> `��rint me DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> yJ7�/p1 Area fs'4 <br /> Application Accepted By____ Date Issued— �_�- <br /> Grout Inspection By <br /> Date Final Inspection By -�•��� Date <br /> Destruction Inspection By Date <br /> _ lvt� �i � .77 �2-�• <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED I CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> AV- 61 poZ� 12 <br /> C-57 WC_WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />