Laserfiche WebLink
07/22/2003 08 46 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORD SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES NIT I QITION <br /> U <br /> JUL 10 2003 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT V <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> j ENVO)NIMENT h&LTH (209) 4.68-3449 <br />� <br /> PERMIT/SERVICES <br /> NOLY4?EFUNDABLE PERMIT EXPIRES 1 YEAS rROM DATE WSUEb <br /> Appiicabon js hereby made to San Joaquin County for a permit to construct andlor install the Work described Thr9 application is made in compliance with San <br /> Joaquin Count <br /> Development ritle,Chapter 9-111,5 3 a d the 6Undards of San Joaquin County Public Health Sernces,Environmental Health DMalon <br /> f:r'&7W Sly o'' •�'-O; *,*e Assessor's <br /> WELL Location lrtf 71 <br /> ='Z 'e <br /> doss street G'�w.a _city. ►�_zip 9s Parcel# r 4 <br /> PROPERTY Owner_-7`r r%WAddress / City.VlOe422:! 1p ��rzl Phone#t��� �7 <br /> 0.67 Contractor�r_��C�t�*f *address%6a � z'� City zip� �lLie# Phene>Ec�_ = �� <br /> Consultant f Sub Contractor __, Address -rL �" d�'CEty�,c# Phone# /� � <br /> 615 Coordinates X _1y ,Township _Range Becton_ <br /> WORK TO-OR PERFORMED <br /> NEW WELL I BORING(CPT,G€OPROSE,HYDROPU NCH,HAND-AUGER,OT"ER') Q DESTRUCTION(choose type below) <br /> Q SOIL BORING# 11 OVER-BORE <br /> *ELL <br /> VERBORE <br /> YELL#_ 4 —7 0 PRESSURE GROUT <br /> *Other ' ` Grout Spa cations <br /> COMMENTS <br /> TYPE OF WELL INSTAI LAMON TYPE CONSTRUCTiO PECIFICATIONS <br /> n MONITORING )(HOLLOW STEM DtA OF BOREHOLE � MULTIPLE CASINGS' la YES 9 NO WELL CASING DIA f <br /> XEXTRACTION Q AIR HAMMERIDR1VEN CASING THICKNESS -%7y 44'0 TYPE OF CASING u STEEL 0 PVC I7 OTHER <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED AUGERS Q HOSE <br /> e( IIRSPARGE Q PUSH POINT GROUT SEAL PUMPED 1]Yes *o (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> L BORING [j HAND AUGER GROUT SPECIFICATIONS <br /> []OTHER OTHERS APPROX BORING DEPTH S OL-MD TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED7� (if YES,list specifications here) <br /> -COMMENTS Gi ,`e- <br /> e �L 1I! GR <br /> NOTE' OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT N 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 ules nd Regulations,and all applicable Callfomia State LawS <br /> Signed x TitWOompany _ _%6_404f— <br /> Print <br /> %6_40 f—Pnmt Name l Oate <br /> DEPARTMENT USE ONLY <br /> 51TE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED j r r <br /> Application AWP BY__.,ZG1 L['i�i - -- Date Issued _1�t Area,_ �� <br /> Grout Inspeobon By Date Final Inspection ByT „Date_�, ,^ <br /> Destruedon lnspeabon By DOM <br /> COMMENTS 1 CONDITIO NS <br /> ACCOUNTING ONLY AID# <br /> CODES FEE INFO AMOUNT REMITTED CHECKS ( REC'D BY DATE PERMIT/SERVICE REQUEST a INVOICE <br /> yL( <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment dot:__,_ 9/27/00 <br />