Laserfiche WebLink
FILE COPY <br /> n p� r WELL PERMIT APPLICATION FORM SITE <br /> RECO �"1 EI-'�� MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> SEP 2 5 2003 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 ` <br /> PERMIT/SERVICES (209) 468-3449 /�_�_ D <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Fff--� 1 <br /> Application is hereby made to San Joaquin County for permit to construct and/or install the work described. This a w' <br /> pp y q ty pe ppliption rs made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> e n Assessor's <br /> WELL Location 75 jjJ I/A LPICO F�e Cross Street 5•77tACy 84ity rRAGy ZiP`75376 Parcel#z�O�/ <br /> PROPERTY Owner CONSD(JAATEA CONiA/AJERAddress 7S- W,tlALPi CO City_jgALr/ Zi&-?36Phone#zo4 2,0-/7/3 <br /> wArE'� n PJ3-3073 <br /> C-57 Contractor f)EJF f--bPi rF_n11-Co.Address Y.O, 80 x I y j cityY!414 A Zip 2's67 LiaeZ�33Z6 Phone# 66- <br /> LrtA/-Wt IC"L50/) Address Sl7Sl{rLL5MLE clt C' L jORAD 0�71s$-d Phone#_ j6- 531-)S.f4 <br /> Consultant/Sub Contractor/q' Ry�yg 8 <br /> GIS Coordinates:X ,Y ,Township 02.5 Range OS"E -- Section 33 <br /> WORK TO BE PERFORMED: <br /> )'NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> a SOIL BORING# a OVER-BORE <br /> ELL#AS-I 7Nkou6H 5-•/2 �f QPRESSURE GROUT <br /> *Other: Grout Specifications: S/o BE�vi 0.v/TE /4s� NE.r rCFwF,uT <br /> COMMENTS: WCLL5 TO BE uSED FoR AIR 06010E SAYIP71 JC <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS /r <br /> (I MONITORING a HOLLOW STEM DIA.OF BOREHOLE 0'9 rr MULTIPLE CASINGS?o YES XINO WELL CASING DIA: �Y <br /> a EXTRACTION )(AIR HAMMER/DRIVEN CASING THICKNESS 0t A3 r TYPE OF CASING: o STEEL XPVC o OTHER: <br /> II VAPOR o MUD ROTARY DEPTH OF GROUT SEAL bR-S/ TREMIE TYPE TO BE USED: D AUGERS XHOSE <br /> <AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 'Yes 17 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: S`�o SENrO.utTE�9s90 NEAT CEwrE/yr <br /> a OTHER: fl OTHER APPROX.BORING DEPTH fl BOLTED TRAFFIC BOX or/`STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? A16 (if YES,list specifications here): <br /> "COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> county Or ances, ules and Regulations,and all applicable California State Laws. <br /> ,��( Pi 63ft� C/✓CiNEek-1ACTdA/ H~ICKELS6AI <br /> iigned x d TRIe/Company d <br /> arint Name 5ILL PRAKT— Date ` -7-3-63 <br /> DEPARTMENT USE ONLY <br /> 31TE MAP IN UNIT IV FILE, ADDRESS: 75 - �• V� t CV 12 u1QC(j <br /> NORK PLAN DATED: C) Q <br /> application Accepted By Date Issued / "' ZS—o3 Are, <br /> rout Inspection By Date Final Inspection BK Dt$ <br /> )estruction Inspection By Date r v <br /> :OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# / <br /> PE CODES FEE INF9 AMOUNT REMITTED CHECK# REC'D BY DAT PERMIT/SERVICE REQUEST# INVOICE / <br /> o / 4 ®p 1 q / <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br />