Laserfiche WebLink
�I 10-24-2000 03 40PM FROM TO -� 15306766005 ' P.02 <br /> i WELL PERMIT APPLICATION FORM SITE <br /> ' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH� MITIGATION <br /> SERVICES UNIT A <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton' CA., 95202 <br /> (209)46$-3449 <br /> NON-REFUNDABLE PERMrr EXPIRES 1 YEAR FROM DATE ISSUED <br /> Apprcation is hereby rnade to San Joaquin County for a permit to construct and/or install the work described. This appllcatlon is made in compliance with San <br /> Joaquin County Development Title,Chapter 1-1141.5x.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Ass#' WELL Location I3l� SDl!-1'v1 ICY� 15 U�Aaf Croas Street ty 5 6 p arcessa�s <br /> -- .1—..�� Ci Zi � Paroet# <br /> PROPERTY Owner ID? Address I _Cfity�_Zip -fpPhone3i <br /> CZ7 Contractor'WOO Waf f{ �i .Address t0 City i0 V 1 7_ip 45 Uc#i 1 �� Phone# a 'I' 6 <br /> Consultant/Sub Contractor t!O.n Addras a l City! P Lith Phone# '�/7�'u�W <br /> GIs coordinates:X Y Township- —.- .... __Range`__ -- ---_ Section___ <br /> WORK To SE E D <br /> EW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER.OTHER') f1 DESTRUCTION(choose type below) ll <br /> 11 SOIL BORING# <br /> JCNELL I <br /> # �'� - - W' fit) 1PR <br /> ]OVER-BORE]PRESSURE <br /> GROUT <br /> Grout Specifications: <br /> IVA <br /> COMMENTS: <br /> r: TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Y.MONITORING *OLLOW STEM DIA.OF BOREHOLE 10 MULTIPLE CASINGS?0 YES )(NO WELL CASING DIA:4 <br /> a EXTRACTION 11 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> 8 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL krL-k _1 , TREMIE TYPE TO BE USED: `AUGERS 0 HOSE <br /> 11 AIR SPARGE Il PUSH POINT GROUT SEAL PUMPED: JrYes -0 N� o OTE: MAXIMUM-FREE-FALL DEPTH IS.30') <br /> a 0 SOIL BORING ©HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: fI OTHER APPROX.BORING DEFER O -N�R0LTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? Itb_(ii 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 done in accordance with San.loaqui6. <br /> County Ordinances Rules and-Regulations,and all applicable Califom' is State Laws. <br /> Signed xVVfAc—xTitle/Company _ LV44i <br /> Print Name Data <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED 1,11w S f 141b <br /> I. <br /> Application Accepted Sy Date Issued S ,�_`t � 1 greg <br /> Grout Inspection --7)-\ Date : 3d 4 Final Ins <br /> pectiortBY� Datg <br /> Destruction Inspection BY Date - <br /> COMMENTS 1 CONDITIONS: Q e w. <br /> ACCOUNTING ONLY: AID;; <br /> PE CODES PEE INFO AMOUNT REfiAETTED CHECKS RECD BY DATE PERMPr I SERVICE REQUEST#_ INVOICE <br /> 3 <br /> C-57 WC-WAIVER„_,,,_, C-57 Letter of AUthoriaation to Sign pertttit__`Encroachment doc__ 9/27%00 6 <br /> TOTAL. P.02 <br />