Laserfiche WebLink
WELLOERMIT APPLICATION FCOOSITE <br /> o ti <br /> (�FF!� /I, i���-,SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> MAY 19 2004 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIROfVi�IEiJT HEALTH (209) 468-3449 <br /> PERiMIT/SERX'ES 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 /> WELL Location')20 W-Lt>-'se+t AU Assessor's <br /> CrossStreet C.1-� `-a -^� City Sr�`- "� Zip�1�2o3 Parcel# 137-137—G/ <br /> lf <br /> PROPERTY Owner t=-S- Wt L�kAV—S Address (-- �'�7r �)I fSSr Ciry STcc n.,� Zip95ZL 2 Phone#tel)4-? S-10Z L— <br /> C-57 Contractor Ca-Sc-t�.oc' OA-,`(—s Address 302- om�-L C�,t.6 LC 1 <br /> Ciry Zip TS'7YZLic# 175/JPhone# f 716) L3k <br /> Consultant/Sub Contractor36, Ki Ly F_jr,rr,3 2�f-ro <br /> Address 7 Cityer> -AA Lic# Phone#(7/0&6F-61/,0 <br /> GIS Coordinates:X ,Y—, ' LT <br /> Township Range Section kD <br /> 'NORK T)BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> Il SOIL BORING#WELL# 11 OVER-BORE <br /> _Mw—Y4, <br /> Other: Grout Specifications: a PRESSURE GROUT <br /> ,OMMENTS: <br /> -YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> (MONITORING u HOLLOW STEM DIA.OF BOREHOLE g" MULTIPLE CASINGS?0 YES ffNO WELL CASING DIA:• A/ <br /> I EXTRACTION $AIR HAMMER/DRIVEN CASING THICKNESS SCk Ya TYPE OF CASING: 11 STEEL )fPVC 0 OTHER: <br /> I VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL `IO 1 TREMIE TYPE TO BE USED: O AUGERS ,1j'HOSE <br /> I AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: flYas p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: N v: C B w-r d�i <br /> OTHER: n OTHER APPROX.BORING DEPTH_ __ ,tBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> :OMMEHTS: CONDUCTOR CASING PROPOSED? ( f YES,list specifications here): <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 /> ounty Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> pned x ` �y Tite/Companyz �PD��S i / <br /> SE tv,.L <br /> fnl Name Date-4CYO,L(L IS 2c'rf <br /> DEPARTMENT USE ONLY <br /> ITE MAP IN UNIT IV FILE, ADDRESS: <br /> 'ORK PLAN DATED: <br /> plication Accepted By _ _ ,_ ,,/1 Issued <br /> a <br /> out InspectionBy VDate Final Inspection By 2_ 7ate <br /> stnctlon Inspection <br /> By Date <br /> )MMENTS/CONDITIONS: <br /> ,CCOUNTING ONLY: AID# <br /> cerw <br /> E CODES FEE INFO AMOUNT REMITTED CHECK# RE 'D B DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# <br /> 57_ WC -WAIVER_ C-57 Letter of Authori ati n t si permit_Encroachment doc_ 9/27/00 <br />