Laserfiche WebLink
Cl7-1C-GC_I✓11 C_I °°-�lt-,I"' '-j[,1._�I'I-.=G.JuG GCIG- F.C.13 <br />C:) <br />WELL PERMIT APPLICATION FAM SITS' <br />MITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 ^ <br />NON-REFUNDABLE PERMIT EXPItZ S 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 applice pT n i 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 �%^� N Mi('( I Cross Street l iC Y� i^ Glt� City :''1(vN f C i�- Zip Parcell- <br />PROPERTY Owner 1-E1eVenI Inn. Address lb"X7-C'9*C1Ve0', l'(-c,S1Pk7DCity o'i Zipc1-1223 Phone# �;c3 c7-77 %7 <br />C-57 Contractor 4F) Address 9 S 6 /\V— Ci GVM vti i Zip 9 4SSS Li roc Phone# `f 2 - 31 3 - SgUC) <br />Consultant / Sub Contractor IF I Cr t Address -IDO �Oi +C4ii� u Eity In CJrc� Llc# IE�J2z Phone# -lZu y' Z3`f <br />GIS Coordinates' X , Y , Township <br />WORK TQ AE, PERFORMED: <br />UNEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") <br />LI SOIL BORING # <br />/',jj WELL # SP-: i <br />*Other: Grout Specifications: <br />COMMENTS: <br />Range <br />Section <br />DESTRUCTION (choose type below) <br />p OVER -BORE <br />p PRESSURE GROUT <br />TYP�F W. 15" INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS — fGp C <br />it <br />p MONITORING HOLLOW STEM DIA. OF BOREHOLE Vi" MULTIPLE CASINGS,, YES � NO. WELL CASING DIA: 2 <br />19 EXTRACTION [] AIR HAMMER/DRIVEN CASING THICKNESS SCh +0 TYPE OF CASING: [] STEEL PVC [] OTHER; <br />n VAPOR n MUD ROTARY DhPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS HOSE <br />AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: 0 Yes ifNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING Q HAND AUGER GROUT SPErCIFICATIONS: -6- r"I+zZ, "i -e `l) �t • ��� -t Ge-rrur 2-711 "1-r�k-1kr( <br />[] OTHER:. _ [] OTHER APPROX. BORING DEPTH .5O f4 . VSOLTED TRAFFIC BOX or a STOVE PIPE <br />I - LL_ 1. CONDUCTOR CASING PROPOSED? (if YES, list specifications here): !� <br />'COMMENTS: L_lC r 1 �TM� Vy E LIJr( �C % % rr C S OLI Li'b PV C. -47 <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 t - <br />Print Name <br />Title/Company C—Iev1e o "7P ` 1-T 60rt" <br />Date i 18l� i <br />v <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />O <br />Application Accepted By <br />�(�� Area <br />Date Issued,zl <br />Grout Inspection By <br />Date <br />Final Inspection By Date <br />Destruction Inspection By <br />Date <br />COMMENTS I CONDITIONS: <br />oI O>/ <br />ACCOUNTING ONLY: AID# <br />S VC) 0 Z q 03 <br />PE CODES <br />FEE INFO/ <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DOTE fT / SERVICE UEST # <br />INVOICE <br />2 2 52- <br />Oz !�I,, � <br />z� L <br />C-57WC -WAIVER_ <br />C-57 Letter of Authorization to sign permit,_.,, Encroachment doc - 9/27/00 <br />09/18/01 TUE 07:39 [TX/RX NO 82841 Z001 <br />