Laserfiche WebLink
04/25/2002 08:20 GEOLOOP PPILLING -j 19165654356 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS -EMD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />N0.079 D06 <br />SITE <br />MITIGATION <br />UNIT IV <br />(209)468-3449 ORIGINAL <br />NON•F#EFUNDAl31 E p>wRfuI1T€Mft�S1 YEAP FROM DATE ISSUED <br />iPPlication is hereby made to San Joaquin County for a perMil to conetnrct and/or in-Vall'tho work doaerilaed. This application ie made In compliants with ,San <br />ijaquin County Dovelopmem Tills, Chapter 9-1115.3 and Ihn Slandard5 0l San Joaquin County PubJlc Health Services, Environmental Health Division. <br />) � CC _ Assessor <br />HELL Lacatlon. - �� MZZ- (JJ Cross Street !_._.. . Cl .J _M,3 Zip Parcalu Z ` 00-01 <br />;lROPERT/ Ownar_ -C1.4 VC tY(�ili�Address�7��rlfgli2['�iO��i I City oOC.t�YI�-.� Zlp���Phanelr <br />•57 Contractor �(-i�' Addrese� �w � ,_�F.c�?ny�� CYJ�,_ City��,�,ZIp�Licd��'� Phor�e� Ki �- �i r 7 '! <br />R � / <br />:ansultantISubContractor� _ Address.,.ji1£�Q_%!�__ /�"r 'LCfty��tte�enl4r��t!_ Phonon!/ <br />.IS Coordinates: XY Township Range somien <br />�QgK TO BE PERFORMED: <br />NEW WELL / BORING(CPT. GEOPROBE, HYDR PUNCt- BAND :AUGER, OTHER*) -5Tmi <br />i0mi9-1yRis. <br />XCIL BORING 4 OVER-EIORE <br />O WELL 4 [) PRESSURE GROUT <br />Other: Grout Specifications: <br />OMMENTS C b?a -;Z.3 + oZ <br />-Yeg OF WELjL INSTALLATION T''1PE <br />I MONITOAING '(HOLLCW STEM <br />I -XTRACTION n AIR HAMMER/DRIVEN <br />I VAPOR Q MUD ROTARY <br />I AIR SPARGE [] PUSH POINT <br />CSOIL BORING O HAND AUGER <br />I OTHER._ O OTHER <br />COMMENTS-. <br />QQNSTRijgj <br />DIA. OF BOREHOLE ! MULTIPLE CASINGS? [] YESNO WELL CASING DIA:_..__ <br />CASING THICKNESS `J TYPE OF CASING; O STEEL O PVC p OTHER:_ <br />DEPTH OF GROUT SEALti r TREMIE TYPETO BE USED: O AUGERS ','HOSE <br />GROUT SEAL PUMPED: loYeS ONO (NOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH_h) [] BOLTED TRAFFIC BOX or O STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ! /�J_ (i1 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 REOUIRED INSPECTIONS. <br />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />:ounty Ordinara Cos, Rules an�ulal:1 a, a d all applicable California State Laws. <br />Thle/Comparty <br />-ItName <br />:TE MAP IN UNIT IV FILE, ADC <br />YORK PLAN DATED: _ L�- <br />DEPARTMENT USE ONLY <br />aplication Accepted By Date Issued L Area <br />rput Inspection By _ _ 0�la Flnetl Inspactlon By ___ -_—_Date <br />,gtruction Inspection By Date <br />OMMENTS / CONDITIONS:­� <br />r.CCOUNTING ONLY: AIDC' :' 00-.Ze '<313' <br />corp <br />�'I_ CODES FEE INFO AMOUNT REMITTED CHECK tr RECID RY DATE PERMIT/ SER INVOICE <br />-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit ffncrocachment dot <br />9/27/00 <br />ST <br />