Laserfiche WebLink
10-24-2000 93 : 40PM FRO' - TO - - 15306766005 P . 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton , CA. , 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Apprioation is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appllcatlon 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 /> Assessofs <br /> WELL Loc <br /> `�- . 1' 1'lyVt,�u\l ✓ Ille� Cross�lStreet U " .S t. city , � �Crl zip `f f _Parcel# 1 ,53 I3�- 03 <br /> PROPERTY Owner r\�,tl %I, iyt o 'rt 4yv CAddress l•`w L. F12 tt II City) r Zip "15005 Phone# 'i914- 9 -5r 15.T <br /> C57 Contractorbr2Hr1 � r�1111`e, �j�+,E': r��y"Address l�U lL`� �' ll� � ci 1u/�in Z zip `i4553 Lic# � 5 L- Phone# ���5�3 i3 — L!) <br /> 11 c?� <br /> Consultant / Sub Contractor)ra6� knVl rtl:1 /11Za1?fl .h Address]�:5t Ctl�A1C•YYI Vpl� l-1: µ '_Ci UifiG"sv1 Lic# Phone# JJDJCf7G-bwn-,'7( <br /> GIS Coordinates: x , Y , Township Range Section <br /> W RK TO BE PERFORMED._ <br /> EW WELL / BORING ( CPT <br /> GEOPROBE. HYD� O.PUNGH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br /> ,SOIL BORING # V-' I -S 1{•Yoo; h GST- OVER-BORE <br /> WELL # P/�tl%_ ( � p PRESSURE GROUT <br /> ^Other; Grout Specifications: <br /> COMMENTS: <br /> TV E F WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _ <br /> 1 <br /> MONITORING HOLLOW STEM DIA. OF BOREHOLE�� � MULTIPLE CASINGS? p YES KNO WELL CASING DIA: <br /> Q EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS B$' TYPE OF CASING: O STEEL K"HVC 0 OTHER: <br /> 11 VAPOR III MUD ROTARY DEPTH OF GROUT SEAL I DD ' TREMIE TYPE TO BE USED: U AUGERS 0 HOSE <br /> 0 AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: Pes G No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AU���G��ER GROUT SPECIFICATIONS: <br /> p OTHER �OTHERi_�_� APPROX. BORING DEPTH Il5 - I4b r iii BOLTED TRAFFIC BOX or n STOVE PIPE <br /> II �CONDUCTOR CASING PROPOSED? 00 ( if YES, list specifications here): <br /> 'COMMENTS' � a I � I crniKi l+li' ni �' ^c, v,�'�5 CrI ;Cr- ^Sj <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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi noes Rule and Regulations, and all applicable California State Laws. <br /> i D <br /> Signedx 7 � - Title/Company JTI �`>�()�U5 ' S� <br /> Print Name Cc. Dpp : � ro ' < Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : _� <br /> WORK PLAN DATED : 11 C_ Co A <br /> Application Accepted By Date Issued 2_ 12. 16` �'/ Area <br /> Grout Inspection By (r.��+�il^ Gt ^ Date z O Final Inspection By 14 Lr n_ lee4- Date <br /> • <br /> Destruction Inspection By Date <br /> COMMENTS f CONDITIONS: <br /> ACCOUNTING ONLY. AID;; FAr5 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE PERMIT r SERVICE REQUEST # INVOICE <br /> SO ( ( . op O (� z aSR9OCJ } S <br /> C-57_ WC=WAIVER_•_,_, C-57 Letter, of Authorization to Sign permit_ Encroachment doc_ 9/27/00 <br /> TOTAL P . 02 <br />