Laserfiche WebLink
10-24-2000 03 : 40PM FP.Oh TO 15306766005 P . 02 <br /> I <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 /> Appr=tion 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 91115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> }, Assessor's <br /> WELL Location ' AVsZI6�W. dJ4xUre40eA W+A e. /(j r / §ie t City iddoil ZIpnr; JG5 Parcel# /1,07nk <br /> PROPERTY Owner1=1 ^ StUt �� �Address <br /> fl.t I 11 City )( Zip4J � Phone!; Aq f337- 2673 <br /> C57Contractorl7ffC7t1 L'r.� � nS��25k� r Address -IJd �1DV%;P P6 —Citygoo - Zip 553 Lic&b-] q Phonen�I7531 ,j5bZti <br /> Consultant / Sub Contractor JVRII()S�II � Ir,rrAt'I�YA,f611Si+1,. Addre5v3)'() U7G1�t'/11I''i1;'� t/: ,'� �SDCi 1 I '`i1 Licft Phone# ./ffj'D 67117 <br /> GIS Coordinates: X., Y T , Township Range _ Section <br /> WERWKYO BLE / BOFORMED• <br /> 11-NWELL <br /> ( CPT <br /> jjjjjjEOOILPR80ORBEIN,GHY#DCd OPUNCH, HAyND-AUGER, OTHER') G DESTRUCTION <br /> G(choose type b <br /> elow) <br /> OVER-BORE <br /> WELL # r7ltrllW7 ( <br /> G PRESSURE GROUT <br /> "Other; Grout Specifications <br /> COMMENTS: <br /> TYPE F WELL INS LLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING OLLOW STEM . DIA. OF BOREHOLE 't)'I MULTIPLE CASINGS? G YES MO WELL CASING DIA:_ <br /> G EXTRACTION G AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: G STEEL ;VC 1.1 OTHER: <br /> G VAPOR G MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS G HOSE <br /> G AIR SPARGE G PUSH POINT GROUT SEAL PUMPED: J3<Yes G No (NOTE : MAXIMUM FREE-FALL DEPTH IS 30') <br /> *OIL BORING G HAND AUGF GROUT SPECIFICATIONS: <br /> nOTHER!.VTHFRCVk APPROX. BORING DEPTH I I5 }POLTED TRAFFIC BOX or G STOVE PIPE <br /> � � <br /> CONDUCTOR CASING PROPOSED?y_ ( if YES, list specifications here): <br /> 'COMMENTS: -�11r'l JiA omni n +WiAA; ''1' P_ bcrir� c <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 Ord�inaance$, R les and Regulations, and all applicable CaliforniaStateLaws. <br /> Signed �ur vw 1 '1Wit/ �' Title/Company � (k [�evlD�i SI <br /> Print Name Sv6i''f IJ ! ' f4 Date JOLZ7-Ob <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED: <br /> Application Accepted By Date issued 2 I Z- 'O/ Area <br /> Grout Inspection By [a Nib , AAA an Date 1 Final Inspection By Ii��-tn,rna Date 5 / z- of <br /> Destitution Inspection By Date <br /> COMMENTS / CONDMONS: <br /> ACCOUNTING ONLY: AID; <br /> PE CODES I FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> Q <br /> C-57_ WC_WAIVER,, C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/27/00 <br /> TOTAL P . 02 <br />