Laserfiche WebLink
WELL PERMIT APPLICATION FORM SITE <br /> E-NItIKOt�I-EI iIlei. HEAL 111 MITIGATION <br /> pvF�W'r ')'FRVICF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> P� (; 3Q <br /> 03 Xt,' -6 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> 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,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL Location j 755 Mtyu F-eRj) A'UE . Cross Street E.A4ARJ1P9A 9D.City �Toc J�roN Zip 95Z{5 Parcel#''_LZIO5�1 1 L <br /> PROPERTY Owner��� �uTG S,� Address�'10.130 X 96010 City SMU L)t'1AD Zio. Z 190 Phone�r{ j,7)5S 9 2)3 <br /> C-57 Contractor G2aGCti I) L4-j IC Address 950 /�wL lZl�. City TnJ ,Zip 9` Lic#�56�}07 Phone# 92S 313"5O <br /> ConsultanIT(t/Sub Contractor,4MUA7-6` NC Address d17Z0Ny8��1 &g, City jQLic# Phone�?� <br /> GIS Coordinates:X 4)9 92.3(!5' tJ^� ,Y 6.17 8m,"E � ,Township � /v Range -7& Section <br /> WORK TO BE PERFORM <br /> SOIL BORING# ER,OTHER" S DESTRUCTION(choose type b <br /> elw) <br /> NEW WELL/BORIN P EOPROBE,HYDROPUNCH,HAND-A IOVER-BORE <br /> ] ELL# � � <br /> 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: S <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I]MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ),_!5 1t MULTIPLE CASINGS? 0 YES VNO WELL CASING DIA: <br /> 0 EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS_TYPE OF CASING: O STEEL O PVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL -7"7) ^-150-TREMIE TYPE TO BE USED: B AUGERS j�H S <br /> AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes M Vo (NOTE: MAXIMUM FREE-FALL DEPTH 15 30E- <br /> B SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: r <br /> g0THER:(�13b9j a OTHER APPROX.BORING DEPTH--1 SD ' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? A)O (if YES, list specifications here): <br /> "COMMENTS:` CST 14i>' L Pj&*S -7 &W=L) , —ISDI Tb �eZLC�f� l��DuI�UI�JItTL�� ��4Yv+pi1 S /`1 1 <br /> 77+r-- Lc��+7/OIVS SNo..�N JAJ FL-, Z �P-1�4S Wl�L aG Gam/ SL° 1 JO Su�FG <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 and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> �� OS I03 <br /> Print Name Date O'M �'z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 3 `75!"-, /1 tjyI in r4 AV en U <br /> WORK PLAN DATED: -I 13 /Gr 3 <br /> Application Accepted By !G�G r i A l d Y h i 2`1 Date Issued 3 Areas 9 n� <br /> Datewn[!L'I 2003 Final Inspection By / Dat Z, <br /> Grout Inspection By V�� r.Qf /YL C L <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: F T Y S — L P Z CPT 3- P <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PE REQUEST# INVOICE <br /> 3501 �'89. a� 89, cc # Oo3 1 '7 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign per Encroachment doc 9/27/00 <br />