Laserfiche WebLink
1 <br /> WELL PERMIT APPLICATION FORM SITE <br /> ,� <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SES VICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHSIIIEHD) <br /> OCY 3 0 ZOO 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> ENV1ROi 1 <br /> i�'CS NON-REFUNDABLE PERMIT EXPIRES t YEAR FRdM DATE SUED <br /> i,.p'i tart rsIer <br /> hereby made to San Joeuui^county fer a permit to Construct and/or instal tie wort described. This application+s made in mmpliarcE with San <br /> Jnago,n County Osvetoprnent'nde,Chapter v i i 15.3 and the Standar-5 of$on Joaquin County Public Health Services.Environmental ses Health <br /> th Division. <br /> N."Ie Toosco +k (098( I�� / C Zp Pace!! s <br /> WELL L0c3ticn�_-lam M1y.1t�+Ft`c.f( /�VGtr^e Cross Street y�k ltt� Cityn9, fio. <br /> FROPEf2"Y Owne�n_ �r� e?t !r�'_J Menne P �,FS'Sy 'Phone#�� - <br /> T (24n 117b 10 <br /> Phon !6 63 5- t65 <br /> G•5?Ccahacto'CAS •Ae UC.I�t�_AddrBss 32 ©me�CiL�c city,cer�o�_Mp SS LLudt <br /> ,/� 5,..re DZ Z SS <br /> Consular</Sub Ca,vactor �oe-Ilq—&Q:'N Address17�64 /4�Wl�D �el(�'�liy <br /> To%nShip Range. Section <br /> WORK.TO EE PERFORiMED: Q DESTRUCTION (choose type below) <br /> 'NEJJ WELL!SGR:NG(CPT,GEGPROBE.HYDROPUNCH,HAND-AUGER,OTHER') Q OV2R-BORE <br /> Q SOIL BORING# PRESSURE GROUT <br /> S e—(3 <br /> "Other, Gr:ut Specifications: <br /> :OMMENTS' SP^ t SP ID arc Vis ` d�ecP SI°-ll -fir SP-!3 ��= Yo '�leeo <br /> 'TVFE 7F WELL iP=w.T'AUA^ON TfPE CON STRlJC?!ON SPECIFICATIONS I <br /> 3 u <br /> Q mOMTORING gNOLLOW STEM E OIA.OF BOREHOLE MU:.TIPLE CASiNYUY.0 YES ONO WELL CASING DIA; <br /> Q EK��CTION ((p�`A!R HAMN:EPuTJRIVEN CASING THICKNESS 5&k40 'TYPE OF CA. ING: Q STEEL jXpVC Q OTHER: <br /> �+Vi;FOR Q MUD ROTARY DEPTH OF GROUT SEAL -7 32 •TREMIETYPETO BE USED! Q AUGERS �,�•!OSE <br /> gAIR SPARGE L PUSH POINT GROUT SEAL PuMper. ;,"es Q No (NOTE: MAXII. <br /> S <br /> QOIL <br /> MUM FREE-FALL DEPTH IS 30" <br /> 6 " 8OF!NG Q HAND AUG:R GROkjT SPEOF!CA.TIONS: a� Ce eM <br /> u OTHER: Q OTHERAPPROX.BORING DEPTH OLTEO TRAFFIC BOX or Q STOVE PIPE <br /> YES.I st speci <br /> CONUUCTdR CASING PROPOSED?�,�I i¶ fcatron5 here): <br /> 'COMA'•ENTS: - — <br /> NOTE: OFFSITE BORINGS REQtliRE ACCESS OR ENCR ACHMENT PERMITS. <br /> �-CALL THE UNIT P.'INSPECTdR 48 V40RKING HOURS TN ADVC,NCE FOR , L REQUIRED IN51'EC710NS. <br /> I hereby ce;ify that I have prepared thin application and that the work Will be do II e in accordance with San OOaquin <br /> County Ordi. nc S, Ru es a d Regtslations,and all applicable California State Li <br /> A <br /> ew tf �To- c o /r y <br /> /'fq T:IceiCompary SQKLO Cf c eO�oG uSt — �e e/—,e <br /> amt <br /> Signed x J <br /> e f �G Date /O 23 O _ <br /> Print Name 4 ate' t <br /> DEPARTIL1iEN7 USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS'_ 0.Ct l L <br /> i <br /> WORK PLAN DATED: <br /> Date issued <br /> hppkatlon Accepted D+ ` <br /> 31 � ( �--'--` <br /> Date � D Fina InSPacdan.By Dale <br /> Grout lnspec�on 2y __ — ; <br /> Destruction msoeation By Data <br /> COMMENTS I CONDITIONS: __ <br /> 'I ACCOUNTING ONLY: I A!D# I <br /> 6. I PERMTYl SERVICE REQUEST# dOICE <br /> i, PE CODES FEE INFO I AMOUNT REMITTED CHECK# RE D BY DATE <br /> 4/27iOC <br /> C-37_ WC=WAIVER_ C-57 Letter, of Authorization to sign permit 'I Encroachment doe_ <br /> i <br /> i <br />