Laserfiche WebLink
<br />ORIGINAL <br />WELL PERMIT APPLICATION FORM <br />.qAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />luitA klil\•JiNVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />oCr. o, <br /> <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 />Assessofp. , <br />WELL Location 2-3 S.63. C • Sc4 Atv1/4 Fe- R. t[ Cross Street City R Wet 14.1 AL zip s3 c"7 Parcel# 4-1-1 I -C7° 1 <br />PROPERTY1 <br />Owner J tr !POI 0-01 Address 23 SCO}A Pkity R ,vtr6M4-zip gs3e7 phone# (201) 838-7S0 <br />C-57 Contractor \/4-‘d Address P°. 13.C)e Li I City zip qs-641 Lic# 12-0q0 q Phone# (41 t)171- 4100 <br />L <br />Consultant / Sub Contractor •St'..4-C$2 .toief,4141c.na Address lyve Nucity Lic# 6 I 02. <br />GIS Coordinates: X , Y , Township 3 SSC' Li k\ Range cl -lack&l— Section <br />WORK TO BE PERFORMED: <br />VIEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) n DESTRUCTION (choose type below) <br />[] SOIL BORiNr. 4 [1 OVER-BORE <br />),WELL #_5-7-It -22 5-2.3. [] PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE (..11 MULTIPLE CASINGS? [] YES XN0 WELL CASING DIA: tr2-Cli <br />CASING THICKNESS TYPE OF CASING: [] STEEL )PVC [] OTHER: <br />DEPTH OF GROUT SEAL 1 TREMIE TYPE TO BE USED: If AUGERS XHOSE <br />GROUT SEAL PUMPED: )( Yes [] No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH ABOLTED TRAFFIC BOX or B STOVE PIPE <br />CONDUCTOR CASING PROPOSED? N c ( if YES, list specifications here): <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, Rules and Regulations, and all applicable California State Laws. <br />Signed x <br /> <br />Ca.r1 S ec109 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 2-550 S. 4R.a4-N -- <br />WORK PLAN DATED: tt-Alf-N 2-t 20c) . COR-u.) et.e02/1. ti <br />Phone# (41I061--0`10 0 <br />TYPE OF WELL INSTALLATION TYPE <br />[] MONITORING >K111OLLOW STEM <br />[] EXTRACTION [] AIR HAMMER/DRIVEN <br />[] VAPOR [] MUD ROTARY <br />o <br />PARGE [] PUSH POINT <br />[] SOIL BORING [] HAND AUGER <br />[] OTHER: [] OTHER <br />Print Name R at\ <br />Title/Company S aC--OR i--ey-r\ 44- o r‘ol, C. <br />Date — <br />Eaa) <br />Area0601 Application Accepted By <br />Grout Inspection By Date <br />Date Date Issued <br /> Final Inspection By JI Date (4 'a-02-- <br />Destruction Inspection By <br />COMMENTS/CONDITIONS: <br />Date <br />ACCOUNTING ONLY: AID# <br />c.) <br />CAC,44. \ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE MIT <br />\ <br />INVOICE / SERVICEREOLIES11_4 <br />5°11. 7-9 52'640 6,-Z ./°(/ Silli a <br />C-571 WC V -WAIVER C-57 Letter of Authorization to sign permit 9/27/00 <br />4-er—e.fr& --04C7