Laserfiche WebLink
WELL4jRMIT APPLICATION F04F SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third 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 /> WELL Location ZS 21.� �U, W SSN NUG-Tbc3 SCrot ` Ac-ao' Ci ty S A) Assessors <br /> ssStreet Zip seParcel# <br /> PROPERTY Owner POwT 01- [4S-Z'3o-•Cp`� <br /> 'Slt'(- ')Address ZZP.( <br /> C-57 Contractor CA-,CNQ:"ULA!!SAddress3C32_ b.-ter— -Vl.c-cC Ciry ( 1M Zip'l Z-Lic#'1/99t7 Phone#(grc)63&-)169 <br /> Consultant/Sub Contractor ' *cfclress3615w'rc� r * CRSS <br /> rj&C`� �"''O"A'�"r ' Ciry Lic# Phone# (� <br /> GIS Coordinates:X ,Y ,Township k AD Range 6� Section ! <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> [I SOIL BORING If 0 OVER-BORE <br /> SWELL# 65-17"AA-64 C,S'-S9 S-173 Tmu,.%h OS-11.8 0PRESSURE GROUT <br /> *Other: _Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I V <br /> I7 MONITORING HOLLOW STEM DIA.OF BOREHOLE l` MULTIPLE CASINGS?O YES ;K NO WELL CASING DIA: y <br /> H EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS SC-0 Ct-17 TYPE OF CASING: a STEEL ' PVC Il OTHER: <br /> — <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEALS �`L. TREMIE TYPE TO BE USED: O AUGERS WOSE <br /> o AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: CYes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING p HAND AUGER GROUT SPECIFICATIONS: S--C- rZ1eTJ k- <br /> 'OTHER: OTHER APPROX.BORING DEPTH 19 '1 ss ' BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? rte_ (If YES,list specifications here): <br /> 'COMMENTS: SyTLS W4L I::v ✓1:.ter�re.1 I��SM �S Ovy+"A*X-P..r� 5!'�"�r�7 `*'3 <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 /> 1 hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,and all appl[cable California State Laws. <br /> Signed x Title/Company <br /> Print Name 'TN-e� -a Y_ PAO'te-'2� Date I of l <br /> DEPARTMENT USE/ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: d as A / <br /> WORK PLAN DATED: { 2'l D -7 q (� <br /> Application Accepted Issue, <br /> 1_Issue /0-3 Area ( r 2 <br /> Grout Inspection By � Dat D Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> Gerw <br /> PE C�O,IDES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST If INVOICE <br /> 161 c� 7 SRO 35543 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc 9/27/00 <br />