Laserfiche WebLink
ID -1 E C E � W E Fp) <br />FEB 1 9 2003 WELL PERMIT APPLICATION FORM <br />ENVIRONMENT HEAL$4, N JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />PERMIT/SERVICES ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />Mw 1 1 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 compliance with San <br />Joaquin County Development Title, Cha 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />00 g, V,--6-.,S�Assessor's <br />WELL Location Ev S}oclk,'�.,�C��ni�t\ Cross Street LVIO)n City�ck� Zip`1SZD'r- Parcel# 137 -?An <br />' ]� <br />PROPERTY Owner MK �10P•*--- &�t- CI Address C11D� Itc11 City &DaF-W` ZipaS�� Phone# <br />C-57 ContractorC--,L?lo(Lktia' GLosc•1L^0L%Address kb35 nvcn.- CitySS-, Zip4521n Lic#4964Z%Phone# LIOG-ZQ)4�2 <br />S,11s, T,lb <br />Consultant / Sub Contractor 0-yi— G" iellti+e, Address]AU12 ►011 U, K- Q61L ru City p1 16 Lic# Phone# 9z5-L1Z6-Zbo'1 <br />GIS Coordinates: X 3-10S-7 1 4011) D , Ya\ 11 1 sq, <br />A <br />W Township 1 N Range 6E Section )b <br />PE CODES <br />WORK TO BE PERFORMED: <br />AMOUNT REMITTED <br />CHECK # <br />[ANEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) p DESTRUCTION (choose type below) <br />DATE <br />[] SOIL BORING # <br />[] OVER -BORE <br />0 <br />J WELL# NW -1 <br />[] PRESSURE GROUT <br />R <br />*Other: <br />Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />[] MONITORING [] HOLLOW STEM <br />DIA. OF BOREHOLE L� MULTIPLE CASINGS? a YES [] NO WELL CASING DIA: <br />EXTRACTION AIR HAMMER/DRIVEN <br />CASING THICKNESS StiIAA(. 41D TYPE OF CASING: a STEEL IPPVC a OTHER: <br />R` <br />p VAPOR p MUD ROTARY <br />DEPTH OF GROUT SEAL b - lot TREMIE TYPE TO BE USED: I}AUGERS p HOSE <br />[] AIR SPARGE Q PUSH POINT <br />GROUT SEAL PUMPED: [] Yes 8 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />[] SOIL BORING [] HAND AUGER <br />GROUT SPECIFICATIONS:��Crb <br />a OTHER:OTHER <br />APPROX. BORING DEPTH Z S BOLTED TRAFFIC BOX or [] STOVE PIPE <br />_G <br />CONDUCTOR CASING PROPOSED? AO ( if YES, list specifications here): <br />rn <br />V 1 <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 be done in accordance with San Joaquin <br />County Ordinances, R s and R ulations, and all applicable California State Laws. / <br />Signed x — A/% i�� Title/Company PRax4 b'7\yd+ �t�S`'/4^ <br />Print Name Y" ' «)t W't i, �►+� S Date Zno/ V I <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: ", <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Insoectio <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />Date <br />Inspection By <br />ACCOUNTING ONLY: <br />AID# r-ntH <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />INVOICE <br />PERMMTSffffVIC # <br />[M, <br />_ <br />R <br />Zoo <br />C-57 WC -WAIVER C-57 Letter of AuthWiz9ff <br />o sign permit_ 9/27/00 <br />