Laserfiche WebLink
WELL P&MIT APPLICATION FORM � SITE <br /> MITIGATION <br /> > t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I - <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95242 <br /> (209)468-3449 KAY 0 9 2003 <br /> N014 REFUNDAIR E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F 01,1 <br /> 1ppllcatian)s hereby made to San Joaquin County far a permit to constrvcl and/or install the work described. This application is nr id ��+camAGant e'withSanTfi <br /> loaquln County Development Title,Chapter 9-1115.3 and the Standards of sari Joaquin County PUNIC Health Services,Env lronmenka-iealtn Dtvisiort:,^�� <br /> 1`vt• � Assessors'" <br /> NEtLLacaflon b w s� cckc Cross Street 1 Cltyi fv l`�a Zip ParcQJrf <br /> 1'Gwner Ad <br /> ^ -�• p q a& Phone:1Z <br /> PROPERr <br /> T�,' dress f• �. ISS City - - J_l�-1 <br /> (� av7q <br /> C-STCondrjctor "A�drtss city �u Uc 3ftiZip��S 71 Lic#1�Friona# 7 U -3 `f-3�U <br /> U „r Lic#a u hone;!_S 3y - l S(¢ - 3 r o o <br /> Consultant!Sub Contractor <br /> 1i rf L'n 1 •e •rte Address � Ctty��� 3 7 - <br /> GIS Coordinates:X. <br /> Y ,Township Rangy Sectlan <br /> S�� <br /> 'LC l0sCd Fr'Sve �•, laC.�F'��� <br /> 1fYaR TO 8E PERFORMED' Q DESTRUCTION(choose type below) <br /> EW WELL!BORING l CPT,GEOPR08E.H RO UNCH.HAND-AUGER,DTitER') Q OVER•84RE <br /> ' jsolL BORING# I a PRESSURE GROUT <br /> I]WELL t1 G/- E - CI t titejCA <br /> Grout�peclficatzor+s. r f <br /> 'Other: a1 , fc ,. 4 <br /> COMMENTS: v <br /> !t J� <br /> TypE OF WELL IIJSTAL AIMN TYPE GONST7iUGT10N SPECTF�#A�QMUL71PLE CASINGS?1)yES '�NO WELL CASING DIA: <br /> 10MONfTORING OLLOW STEM CASIN 80R7=HOER —_ <br /> ' � TYPE OF CASING: f3 STEEL , PVC fl OTHER: <br /> fl EXTRACTION QAIR HAMMER/ORIVEN CASINGTHICiWE55 ,_ <br /> QFFpTH OF GROUT SEAL D `+ 7rtENtIE TYPE Tq BE U5ED' AUGEFtS Cl HOSE <br /> 3]VAPOR Q MUD ROTARY No NQ'j-E; MAXIMUM FREE-FALL DEPT)•i,l 30 <br /> GRCIJTSEALPUMPED: tYes Q t a• 6cti7'('i <br /> Q AIR SPARGE a PUSH POINT L e',c K'f ruv 6 l <br /> SOIL BORING 62 <br /> d HAND AUGER GROUT SPECIFICATIONS: _ ,r SOLO (RAFFIC BOX or Q STOVE PIPE <br /> APPROK BORING DEPTH., ti 5 4 <br /> 11 OTHER OTHER_ If s,lief sgeei5cat;ans here}: <br /> CONDUCTOR CASING PROPOSEO? t ff r.o h <br /> • ) ���re r S tt fwC`e <br /> Jel� t Insy-ti <br /> •cnMMErITs: �. d u 'BK <br /> a NOTE: OFFSITE BORINGS REQUIRE ACCES OR ENCROACHMENT PERMITS. <br /> L THE UNIT 1Y INSPECTOR 48 WORKING HOURS 1N ADVANCE FCR AL1.REDUIRED 1NSPECanOJoa•Joaquin <br /> CALL <br /> arab eettl that I have prepared this application and that the work wi11 be dons in accordance with 5 q <br /> I It Y u tiat+s,and all appliGahle California State Laws. t <br /> county Ordina es,Rules and Reg ,l�C .,c <br /> TitlerCampany <br /> Signed Date S' -7-03 <br /> NniNamaDEPARTMENT USE ONLY <br /> S17E MAP IN UNIT IV FILE, ADDRESS: a <br /> WORK PLAN DATED: 3 Area <br /> Date Isauea ? <br /> Date �- <br /> A;N29mllon AeCSPted BY Date jj Final InapecL;cn By <br /> Grouttnspecaon BY Data <br /> Oc5uuctien Inspedian BY <br /> CoraMEWS r CONVITIONS: If <br /> ACCOUNTING ONLY; AJC <br /> R 'D 8Y DATEr PERMIT 1 SERY[CE RECUEST# INVOICE <br /> 1E <br /> PE CODES FEE IKFO AYAOVN7MTTTEQ Ct ecK# Et: <br /> 9/Z <br /> sign <br /> sic <br /> C-57 WC�.V/�4IVER.� C-571.e1 ter of Authorization to sign permit —gncraathme�rt c3ac� <br />