Laserfiche WebLink
Lea <br /> 10-24-2000 03 40PM FROM TO 15306766005 P 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> VC (0 Py MITIGATION JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT M[TlCAA <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> IV <br /> 304 E. Weber, Third Floor, Stockton, CA,, 95202 <br /> (209) 468-3445 <br /> NON-REFUNDABLE PERiNTf EXPIRES 1 YEAR FROM DATE L LED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described This appilcatlon is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115 3 and the Standards of San Joaquin Co'my Public Health Services.Environmental Health Division <br /> WELL LooaL—Cross tion all f'JA�.[,iJlh�I 1"dJy) �ti Street - City T im Zip Paroei# <br /> PROPERTY Owvner_A Addee5A +o' � II Cirty� PAloul Zip it+Z 3Phoneti <br /> C-57 Contractor IR�L V +Ii[� l0, Address lac7 L��1 Pho[1e �- Y <br /> cc ffAn I <br /> Consultant/Sub Contractor <br /> .ITT 'S FA✓, T.-(. Address 3�iJ 4arr[ts+rl I Gtyl�� -- �L phone#>']v 7b-� <br /> GIS Coordinates X f_ Township. I -Range P, L SeC�on `j <br /> WORK ToSE P_EREgR_Mg� <br /> [I NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH HAND-AUGER OTHER-) DESTRUCTION(choose type below) <br /> I]SOIL BORING# XOVER-BORE <br /> 11WELL# (]PRESSURE GROUT <br /> `Other, Grout Spea6ca[ions � <br /> COMMENTS Dr,i1 ,, a� I�u�"1i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r( <br /> II MONITORING AHOLLOW STEM DIA OF BOREHOLF-,. J0 . MOLTIPIE CASINGS?Q YES B NO WELL CASING DIA.,, <br /> (]EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING U STEEL )(PVC n OTHER - <br /> �APOR [}MUn ROTARY DEPTH OF GROUT SEAL 31 I TREMIE TYPE TO BE USED a AUGEi�S Q HOSE <br /> MVI]AIR SPARGE a PUSH POINT GROUT SEAL PUMPED Wes bNo <br /> MAXIMUM FREE-FALL DEPTH IS 3a') <br /> 11 SOIL.BORING 1]HAND AUGER GROUT SPECIFICATIONS <br /> I <br /> (I OTHER a OTHER APPRO>L BORING DEPTH � ( L a BOLTED TRAFFIC BOX or 13 STOVE PIPE <br /> l} j CONDUCTOR CASING PROPOSE I' (if YES,list specifications here) _ <br /> -COMMENTS I I 7 VW-15 <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 0rdinan es, Rules and Regulation$, and all appllcable California State Laws <br /> -- � r <br /> Signed x.�� f V�� Tstte/Company <br /> Print Name I l' I Date (- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z5775S. N SSG1 T�S5 <br /> WORKPLAN DATED: 15 CaGfqq��ea' ZDU I <br /> Application Avepted fay tQI aet Date�ssued l � � � _Area__ 53 <br /> Grout Inspecton$Y Date Final tnspection By n� �.�---- <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS <br /> isACCOUNTING ONLY A10"m <br /> PIE COCIES FSE INFO AMOUNT REMITTED CHECK# REC'D RY [DATE PERMIT 13ERViC> REQUEST a1 INVOICE <br /> 5D z �c ('0 5 y� CAJ �C o o��t 1143 <br /> C-57_ INC -WATVER_ C-57 Letter of Authorization to sign perm+t Encroachment doc 9/27/00 <br /> TOTAL P 02 <br />