Laserfiche WebLink
Area 06E/ <br />Date Final Inspection By <br />Date <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS! CONDITIONS: <br />9--t 1-0 / Date Issued <br />hM, 76'"bate 7-24. 0 <br />ORIGINAL <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 />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 />WELL Location SZ:CA (IOC tC1C- 1,-- Cross Street n r. city Stoc-k. 4 zip cf 52 o 7 parcel# t c-,-L- 2 7,:.' -Oa <br />xok,, n hct)d. , Assessor's <br />PROPERTY Owner 5 )1 6311.::). Address 2-7-/TI.pg fb.e.. ,C;-4•L /4-i.AQ City -St° r., rte., 31 Zip 752,0 7Phone# 20 ?/.9 5,2. -C1.7-7 <br />C-57 Contractor kie5it 1-?"-D ---WYMt Address 3153 F--,t2.3tVIlici. Rd City ftil.:V./1 Zip 5-7412.Lic#5.5"-1/7(iFhone# c-iv61,76' -72 7L.: <br />Consultant/Sub Contractor E0..(6.1,4.14,t-Address /WC ,ttilecr... ii-IlitY Raceh i # &-X:T/rPlhorie#'71%.31;t / <br />,Township <br />WORK TO BE PERFORMED: <br />XNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />U SOIL BORING # <br />71WELL # t 1-3 <br />*Other: Grout Specifications: <br />COMMENTS: <br />El DESTRUCTION (choose type below) <br />0 OVER-BORE <br />1] PRESSURE GROUT <br />0-\ <br /> <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING 'HOLLOW STEM <br />0 EXTRACTION a AIR HAMMER/DRIVEN <br />VAPOR 0 MUD ROTARY <br />?kAIR SPARGE 0 PUSH POINT <br />0 SOIL BORING U HAND AUGER <br />0 OTHER: 0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE ( ' MULTIPLE CASINGS? 0 YES *NO WELL CASING DIA: ,) <br />CASING THICKNESS L ke,/ th) TYPE OF CASING: 0 STEEL A PVC 0 OTHER: <br />DEPTH OF GROUT SEAL &I TREMIE TYPE TO BE USED: G AUGERS 0 HOSE <br />GROUT SEAL PUMPED: AYes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: f::',‘-'1,1720-i4., <br />APPROX. BORING DEPTH 7C) W3OLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? N6 ( if YES, list specifications here): <br />*COMMENTS: <br /> <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 2-e-o lay S "L" Title/Company LiGtef,201 <br />tie chz1-vv\ <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />SITE <br />MITIGATION <br />UNIT IV <br />GIS Coordinates: X , Y Range Section <br />Print Name Date <br />DEPARTMENT USE ONLY <br />/0 10 <br />ACCOUNTING ONLY: AID# <br />FAC# <br />_ <br />-. <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE p - t, r : QUEST INVOICE <br />iliq VI lit/ gl 15-iy ottz- sR# 02.7f 7 <br />-57 Letter of Authorization to sign permit rnnchment 9/27/00