Laserfiche WebLink
11/30/2000 15: 21 <br />-IRMWED <br />I NJ- � �- <br />APR — 2 2001 <br />ENI\/1P9,JMFfdT HFAITH <br />2094683433 <br />FIFTH FLOOR <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />PAGE 02 <br />DR I <br />KIA IL <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES I 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 �J -S. �� ucL -�I Cross Street fi T. city,a2k() Assessor's <br />�"� 1 =�"fir .,,` Zip <br />95%+Oi� Parcel# <br />PROPERTY Owner Cry) f Scuxai 46 P.1 .Address &S� �r gel I �. City J ut ior-L Zip M Phone# <br />C-57 ContTactor.w(d?QYdTJnJIi�Address`t-)DIadx -City �ILn, Ui `7u� Lie#� C% 1Phone#/Co�9D y <br />Consultant 1 Sub ContractorE� k"— F(II)Qaj r1a Addresscj IUDCP�\C) I �rCi1y���,Y1/�{fl,ILiC# �iO l <br />GIS Coordinates. X <br />Y <br />Township <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (O -PT, GEOPROBE• HYDROPUNCH, HAND -AUGER, OTHER") <br />0 SOIL BORING # <br />(I WELL # <br />"Other: <br />COMMENTS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />:,MONITORING <br />[IHOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMERJDP,IVEN <br />:VAPOR <br />U MUD ROTARY <br />(I AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />U HAND AUGER <br />i] OTHER'_a <br />OTHER <br />-COMMEN <br />IM <br />Range Section <br />d <br />DESTRUCTION (choose type below) (r` <br />;{„OVER -BORE j <br />PRESSURE GROUT <br />v n, <br />CONSTRUCTION SPECIFICATIONS <br />DIA_ OF 20REHOLE MULTIPLE CASINGS?[] YES Q NO WELLCASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />DEPTH OF GROUT SEAL TREMIE TYPE TO 0E USED: U AUGERS U HOSE <br />GROUT SEAL PUMPED; 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH a BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED?7— ( if YEs, list speci_ficL/a_tions here): <br />&C \�� \_1.S��'( n Ck –0V /1 0 _S+YI Ar`� i n n /1l ( 4h-)rk x: -L <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 Ordinances Rules a d Re ulations, and all applicable California State Laws. <br />Signed x itle/company GCo fo y, y <br />Print N <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS:,t-- <br />WORK PLAN DATED: 3 - Zoo <br />Application Accepted By Date Issued <br />Grout Inspectlon By Date Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />0/0 <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMFrTED <br />CHECK A RECD BY DATE PERMIT I SERVICE REQUEST A <br />INVOICE <br />�5v Z <br />c,� � <br />�• � <br />2 • b 25 <br />C-57 We -WAIVER C-57 Letter of Authorization to sign permit Encroac n oc 9/27/00 <br />