Laserfiche WebLink
• • ORIGINAL <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 `rIRDtj c�C <br /> t Y (209) 468-3449 `1 DFF <br /> cef <br /> NON-REFUNDABLE PERMIT 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 Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL Location 2(4o, S I'laJoliwc Cross Street J�d City 1'racrrZip 537 G Parcer# .1�/6•-l3C-G 9 <br /> PROPERTY Owner Crtu ol- 7(Y,cN _Address 520 J, lra6� (3��� City T(Y.rG TZip 5376 Phone# 6.2 Of) y21 -VL//0 <br /> S"'' 705WPhone#(510)_54,y-7�76 <br /> C-57 Contractor V'rorTex Address 2ho Ada,h5 slue, city-Lea,,��o Zip yyS�/Lic# <br /> ,1 ,,,1 tL Da%�•�� <br /> Consultant I Sub Contractor Acroo / rlckelSwn Address ;GLI? /{f NjC(1 l) Ij City HILCS Lic# l� 550$ Phone# (f/6� 93y-7S`-'L <br /> GIS Coordinates:XG1T 37,71Dg�Y7 ,YLVL,6, ya 1,`1253'YY�Tormship C0..2 S Range (7� Section 33 <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> �EW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 OVER-BORE <br /> .4SO1 BORING# UG -HP7 <br /> O'WELL# I14byr= 0PRESSURE GROUT <br /> *Other: _Grout Specifications: nect4 CPmf6-t <br /> COMMENTS: Enc. ac rnt. Y�ermr ,n 51reef <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> U MONITORING 1]HOLLOW STEM DIA.OF BOREHOLE /7t; MULTIPLE CASINGS?DYES ONO WELL CASING DIA:MA <br /> tl EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS LVATYPE OF CASING: O STEEL 0 PVC p OTHER: <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL -i�-t=I de_�TREMIE TYPE TO BE USED: 0 AUGERS tibOSE <br /> AIR SPARGE $PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: /2ZQnf- Co:n>nt <br /> 0 OTHER: N OTHER APPROX.BORING DEPTH S0 Yet a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? NO (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 yand Regulations, and all applicable California State Laws. <br /> Signed, 7; —2 �t/"+1+� �! Title/Company Fra�ect_ cnr. Qct,� M'cl<elsor� <br /> / <br /> Print Name I�r�OIr rt-. L. kclmvn D.N8 Date, <br /> DEPARTMENT USE <br /> ONL <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Uj V <br /> WORK PLAN DATED: �7 <br /> Application Accepted By Date Issued�!/ 9� Area <br /> --ff <br /> Grout Inspection By Dale Final Inspection Grout Inspection By Dale Final Inspection By ate <br /> ry3cv <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# cn�� <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> o -e JP b 12-- <br /> C-57 <br /> ZC-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br /> �T'to3�Yoo <br />