Laserfiche WebLink
3Et-✓- 2S g <br /> � ij`; II`_,';i WELL ERMITA;PPLICATION Am F ' <br /> WECOM <br /> AUG 2 7 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ,j , _,,_t ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> ENVIRvIV;aEP,, r,_hu�i <br /> PER�iliTrSERv',;ES 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 d �S <br /> NON-REFUNDABLE PERMIT EXPIRES'I YEAR FROM DATE ISSUED �✓/ r�'v <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 Devel 4/4 pm t Tid Chapter&1115.3 and the Standards of San Joaquin Coun Public Health Services,Environmental Health Division. <br /> WELL Location Cross Sheet f Assessor's <br /> Zip Parcel# <br /> PROPERTYOwner_CID' Of ,bra Al AdlNE[Oc+eocd S City_Srcr t7vn/ Zi 952oz <br /> P Phone# Zoll 8241 ?Z/68C-57 Contractor (.l�fEfct 1�ll Address e 1730L /7( Ci <br /> tyfst..tn.X.' Zip93'Y7J Lic# C81 Phone#10� SYL 1L3z. <br /> Consultant/Sub Contractor 4ol CFdi vF F,,,,�.rc6 Adl PI/✓fL✓-f /2'rp t Ci / <br /> ty!;'M/4IY/ Lic# ±✓�. Phone#510 CSL trrDO <br /> GIS Coordinates:X ,Y ,Township Range g Section <br /> WORK TO BE PERFORMED, <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) <br /> H SOIL BORING# p DESTRUCTION(choose type below) <br /> D WELL 11 GFw-2r D OVER-BORE <br /> 'Other: 0 PRESSURE GROUT <br /> COMMENTS: Grout Specifications:: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLEJL i <br /> XTRACTION D YES MULTIPLE CASINGS? ll''' WELL CASING DIA: <br /> _ <br /> ,lLlE <br /> -kl <br /> p AIR HAMMER/DRIVEN CASING THICKNESSSLt Rt) TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR �"UD ROTARY DEPTH OF GROUT SEAL 0-90' TREMIE TYPE TO BE USED: <br /> 0 AIR SPARGE 0 PUSH POINT GAUGERS OSE <br /> GROUT SEAL PUMPED:fres 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 31 <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: yE.oY CF' A rT <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH /zo' <br /> "BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 'COMMENTS: CONDUCTOR CASING PROPOSED? /✓ (if YES,list specifications here): <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed z v Y �iTitle/Com an �jtg�e� yO�lc[/ <br /> P &sOGTT <br /> Print Name_f7lt/ ' rc ria.rlG—'�c. Date j�ze / <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRES <br /> WORK PLAN DATED: 'U/ <br /> Application Accepted By ©� <br /> Date Issued Area <br /> Grout Inspection By Date Final Inspection Br''-' <br /> Destruction Inspection By �_Date�i� a <br /> 27 <br /> Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> i <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RE 'D BY DATE .PERMIT/SERVICE REQUEST# INVOICE <br /> 12Qo <br /> I WC_ WAIVER_ C-57 Letter of Authorization to si n permit_Encroachment doc_ 9/27/00 <br />