Laserfiche WebLink
WELL PERMIT APPLICATION Fd'RM SITE <br /> TION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> UNIT A <br /> OR!o tier"tirdHEALTH DIVISION (PHS-EHD) <br /> 52 304 E. e , 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 /> ��� � Assessors <br /> WELL Location ►3pp9�� S Ce ke-LPSU Cross Street W"W. city n zip p�Z Parcei#(�'1�3oo-IZ <br /> PROPERTY Owner��2uRcn�>t to/o . Addre[s�s600k %conn&6J>» QU City � per+-I�Io'1�Zip_L Phone#Ck 5"-Zq Z-1n,a <br /> C-57 Contractor V}W �C2�.�/t�n�t Address?o ,7. �l�w 1 City,S\CN6-A Zip at 41 Lic4lZ010 Phone#��W����-41Z <br /> Consultant/Sub Contractor 1J Address36n k.�`%pre— #150 Cih'gm1ic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> VIEW WELL I BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# Q OVER-BORE <br /> WELL# S 0 PRESSURE GROUT <br /> 'Other- Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONSPELI /! <br /> MONITORING �' OLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES ONO WELL CASING DIA: <br /> 0 EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL PVC 0 OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 3/ r TREMIE TYPE TO BE USED:ciLAUGERS 0 HOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: ' ,_'es p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 1* a C32t�ri� <br /> Q OTHER: Q OTHER APPROX.BORING DEPTH 3Z� �S-1 7 W15,0LTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? Ab_(if YES,list specifications here): <br /> *COMMENTS: l`AQ l\V!SL M A.+e- �Z� ke-e <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 /> CountyO Rules and Regulations, and all applicable California State Laws. <br /> Signed x �' Title/Company .�TAtt SG�er��l c� SC: <br /> Prins Name 3(�dtJ S i�ylc� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 3 5 CC?r\+C,-�- — <br /> WORK PLAN DATED: U // 10 -( <br /> Application Accepted By Dot L5' --"4n Date Issued % I G -- � � Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS f CONDfTIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMrrTED CHECK 1t REC'D BY DATE PERMIT 1 SERVICE REQUEST 9 INVOICE <br /> t� lf,�! �3, <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/0 <br /> £0 39Vd 600-IA HIAId ££G£89060Z T£:£1 000Z/q0/ZT <br />