Laserfiche WebLink
WELL-PERMIT APPLICATION FfiRM 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) 468-3449 <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 compliancewith San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin Crounty Public Health Services,Environmental Health Division. <br /> MAfKp7 ST-/ Assesso(s <br /> WELL Location ( 5 tA11'I$p ' Cross Street W�IS_on�_Ciry 57nc Kinn Zip �$2o1 Parcel# <br /> ToLVTOn , Z Sr K,.r Zi 9S2°I Phone# y -3 � <br /> PROPERTY Owner D &ALQ.1'�_ ` Address I01 S. W1��Sa n IQIA syry,, City P b <br /> Onlhr� -3233 . /4t.yrr�125�,� HAiyt,49 zp9574 Lig155997Phone# ) 3&7L71a <br /> C-57 Contractor IAIEsT Pu- �'I Ad ress Tai}E 17 City <br /> Consultant/Sub Contractor e c; , E Address `SNAW R City aS10r'KT'(lic#4dou7Phon 2Dy 19D010 <br /> GIS Coordinates:X <br /> y_,TownshipRange Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> ' 'NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') N p OVER-BORE <br /> /'� Q SOIL BORING# []PRESSURE GROUT <br /> WELL# Mw-V7 Mvv' 7 <br /> 'Other. �—Grout Specifications: <br /> COMMENTS: IF_ K I Wij 11 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �i <br /> MONITORING )IOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?()YES AND WELL CASING DIIAA;11 � <br /> !0•-EXTRACTION AIR HAMMERIDRIVEN CASING THICKNESS `x4y� R y�PE OF CASING: D STEEL VC �OTHER:� <br /> VAPOR MUD ROTARY DEPTH OF GROUT SEAL I O F£i} TREMIE TYPE TO BE U XAUGERS HOSE <br /> p AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: N" Cf MQ T <br /> p OTHER: 0 OTHER APPROX.BORING DEPTH ISLP � J BOLTED TRAFFIC BOX or p STOVE PIPE <br /> S 0 1"05 7 CONDUCTOR CASING PROPOSED' No 'l tiff YES,list specifications here): <br /> 'COMMENTS: L i v2 ysji 11 <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 Or inances, Rules and Regulations, and all applicable California State Laws. 5� cIYAn�� <br /> O T (7Fo ��ron. <br /> Signed x Title/Company Q <br /> e2 <br /> _ Date / <br /> Print Name DEPARTMEN USE ONLY �� L <br /> SITE MAP IN UNIT IV FILE, ADDRESS: O l (A) t Son 5- 6 c-�r ' <br /> WORK PLAN DATED: ,A �a <br /> Date Issued -1 Ia-( I b Area 7 Z <br /> Application Accepted By Date <br /> Grout Inspection By YY�° s Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: AJG <,C rep n 1 er 0a f 5 f R'r •` <br /> 0. 41t <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 350 ( B I g 5tAi " -5 a <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_. 9/27/00 <br />