Laserfiche WebLink
06/19/2000 03:30 925-463-2559 ATC PLEASANTON, <br /> F I L E <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PWS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> . (209)468-3449 <br /> ^ON R"UNDABLE PrAMIT EXPIRESI YLVAR FRRM 0 90E <br /> gppllealWn Is hereby made to Ben Joaquin County tar a permit to rAns><uet and/or insan the work described.This appumuon is made in compliance with San <br /> Joa4uln County Dev2e�lvpmenntTItle,Chapter&1115.3 2nnd.the Standards of San J/oaaQuinn County Public � <br /> Health SerIAogs,Environmental Health Division. <br /> WELL Caution ✓✓O? � '�j,� Gross Street <br /> PROPERTY Owner /G17u ^�/• d�����J �d{dress �D �/� 5���j Gty �j P /�I,y�l�`hanolF ��•j� yy 1n` <br /> C•67Contractor � �/r�//�6�Add�dtmss? 3; <br /> Consultant 6uS Contractor .7 Jyr' Address /n1� ItJ G Ph ti <br /> GIS Coordinates:X ,Y Township.. Section <br /> WORK TO Sq PERFORNM <br /> �� r�� �ryt DESTRUCTION(choose type below) <br /> 0 NEW WELL/00RING{CPT)SOI LBORING1f /// J EA`) a n OVER-BORE <br /> p W ELL S -' n PRESSUR5 GROUT <br /> 'Other, Grout Spedfications- <br /> COMMENTS: <br /> TYPE OF WDLL INSTALLATION TYPF CONSTRUCTION SP- t IFICAMONS <br /> p MONITORING 11 HOLLOW STEM DIA,OF BOREHOLE MULTIPLE CASINGS?11 YES ONO WELL CASING DIA.,_ <br /> 0 EXTRACTION p AIR HAMMEP/DRIVEN CASING THICKNESS TYPE OF CASING Q STEEL 0 PVC O O HER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_TREMIE TYPE TO SE USED: O AUCEFs 0 HOSE <br /> 0 AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 11 HAND AUGER GROUT SPECIFICATIONS: <br /> p OTHER-.0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 11 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? {if YES,list specifications here): <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 I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinanc_ es,Rules ang Regulations,and all applicable California State Laws. <br /> Signed A� . <br /> Print Name E/Q w 0�7 " Date <br /> DEPARTI1i'll^IVT URE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �sJS « G <br /> WORK PLAN DATED: <br /> Application Accepted 13y Date Is:3 <br /> ued Area <br /> Grout Inspection By Dale Final Inspection y Date <br /> Destruction Insgodon By Date <br /> COMMENTS ICON DrflONS: <br /> ACCOUNTINGONLY: AID,# <br /> PE CODES FEZINFO AMOUNT RIIMRTED CHECK 0 RECD BY DATE PERMIT r SERVICH R9QUESTS INVOICE <br /> C-57_ WC^-WAIVER C-57 Letter of Authorization to sign permit--Encreeehment doc`�`• 9/27/00 <br />