Laserfiche WebLink
WELL PERMIT APPLICATION FORM 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 /> / J . _ �J Assessors J„ <br /> I <br /> WELL Location_ 7Z ! /. ' k (4?1 Cross Street.��lhC JOfil!I City �Tcr}CTonJ Zip SLO Parcel# '0 -)z <br /> PROPERTY Owner�YG�J 1 (/ F1"t'AV S Address. PG �q la00 _City ST ti Zip_`- phone#e <br /> C-57 Contractor Fua20 GC-oSu4�+cFSy/AJf Address/ppQ 8eom WA,t SrrG L440 City 0AW�}At0 Zip"607 Lic#7120/3 Phone--G1o�21,7-1114 <br /> Consultant/Sub ContractorLwyene&kT,4 7&9JAje_ Address Cit}!�'7D(,f To.y Lic# Phonerlb�`f—OSIk <br /> uJTG t <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> '(NEW WELL I BORINGPT EOPROB YDROPUNCH HAND-AUGER,OTHER-) S SITE S DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: 7� -rrrCAAAAAj '• -Griq R,<,u7pfir1'6 <br /> COMMENTS: S GpT Bort7b l20'' S 11y, A,u.A Bbl=. Ta ISA' : I'Gf. RF Tb ISS' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE " MULTIPLE CASINGS? 0 YES KNO WELL CASING DIA:.U,4- <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL-Ti') SaeJ=A,:e- TREMIE TYPE TO BE USED: 0�n�CC0 HOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: VYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: X114{7- Geyvt-- l! <br /> r- <br /> OTHER: C.PT n OTHER_ APPROX.BORING DEPTH r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? 4�0 (if YES,list specifications here): <br /> 'COMMENTS7" 5Ol-lrlel�llUC� [� —15e)r, ct�,-t i�eT AAL{L.ripLrs <br /> hdpi-c :j-AF S SITS ^.in / n)L.jz /yci eil- NE Gl?T SJTE S <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 Ordina ces, Rules and egulations, and all applicable California State Laws. <br /> Signed x Title/Company y' FF <br /> Print Name C,a �y ej-P F Date <br /> DEPARTMENT USE ONLY <br /> ��—T <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> -TEjTGrout Inspection By Date Finat Inspection By ateG <br /> Destruction Inspection B Date I <br /> COMMENTS/CONDITIONS: I ✓l E. Cir <br /> ACCOUNTING ONLY: AID# ` <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D Y DATE PERMIT/SERVICE REQUEST# INVOICE <br /> —tv-- Ss �- o <br /> r'_�i7 \A/r- -1AIAT1/FD C-�:17 I ottor of Aiit'nnri-7nti to <Inn nermit Fncreechment doc 9/27/00 <br />