Laserfiche WebLink
r WELLPERMIT APPLICATION ARM SITE <br /> 22 pp� MITIGATION <br /> ZErI_� \"� D UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> MAY 9 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) 7`7 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> "tALTH r 4 kq (209) 468 3449 `/I u <br /> PE`�.Q:;ITISER`JiCE CGS -RR1 —-7_ o I <br /> ©�I, n t''l sct(�tl NON-REFADABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> pplionris\hereby made to San Joaquin County fora permit to construct andlor Install the work described. This application <br /> made Assessors with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of`San Joaquin County Public Health_Z Ps•EnvironmePna cel#Health Division. <br /> Cross Streets `-n \\nS1CIS `,IF.n.FF. rr�� 1 _ ppe�rr '' <br /> WELL Location .�� S cityv-.oH Zi Ty�D� Phone# �� <br /> (� /.ter o tl..._., t•V� DN t2� p �9o7LiPi) q&5 ¢¢ ��YY <br /> Q�,,.t.. tp%fn nAddress �J3Uc hone# '7�-3I`) w? <br /> PROPERTY Owner tlo+t Ciry �n _Zip� #� <br /> \�c n Address qz �' r� 0 4 10`{00 <br /> Cbl ConVactor $ (,�v Llc#�4�Vg8 Phone# V&` <br /> �•/�,r,f,•� Address�n '� Cityk� <br /> Consultant I Sub ConVaclorJGlV Section <br /> Township���nge�-� <br /> GIS Coordinates:X_ -Y� <br /> WORK TO BE PERFORMED: o DESTRUCTION(choose type below) <br /> 11 OVER-BORE <br /> EW WELL I BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER ) Q PRESSURE GROUT <br /> OIL BORT G# �{ <br /> W ELL#���—Groul Specifications: <br /> 'Olher- <br /> COMMENTS: <br /> •7 I <br /> INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS W ELL CASING DIA: L <br /> TYPE OF WELL �—� DIA.OF 80REHOLE I0 MULTIPLE CASINGS?17 YES O VC []OTHER: <br /> 'MONITORING HOLLOW STEM TYPE OF CASING: Q STEEL <br /> p EXTRACTION Q AIR HA CASING THICKNESS 6 <br /> D VAPOR Q MUD ROTARY <br /> DEPTH OF GROUT SEAL'^ / TREMIE TYPE TO BE USED: O AUGERS HOSE <br /> U AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Q Yes Q No (�N��k MAXIM <br /> FREE-FALL DEPTH IS 30' <br /> SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: <br /> OLTED TRAFFIC BOX or STOVE PIPE <br /> OTHER p1APPROX.BORING DEPTH if <br /> YES,list specifications here): <br /> p OTHER: CONDUCTOR CASING PROPOSED? <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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or les and Regulations, and all applicable California State Laws. <br /> 71lleluompany 1�4P'c' �`e�p�� <br /> Signed x ' / - Date /V/O <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ti�tfiPi <br /> WORK PLAN DATED: l7 <br /> &Z; <br /> Date Issued S �L I C) I Area <br /> Application Accepted By Date <br /> Grout Inspection By Oats.�Or Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 00Li.3«�-1 I III 19 �1 Q4)-D(O t 8 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> 9/27/C <br /> £0 3cJdd <br /> 2100-13 HJ.dId ££4£89PSOZ TE:£T 000Z/V0/ZT <br />