Laserfiche WebLink
10-24-2000 03 40PM FROM TO 15306765005 P 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> (0 Py SAN JOAQUIN COUNTY PUBLIC tit MITIGATION <br /> �ALTH SERVICES UNIT A <br /> ENVIRONMENTAL. HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95242 — <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicadgn is hereby tr=ade to San Joaquin County for a permit to constrict and/or install the work described This application is made,n Compliance with San <br /> Joaquin County Development Title,Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services,Ernnronmental Health Di%nslon <br /> �} Assessor's <br /> WELL Location 25 ! f.5 1 �Jl�R"L�--Cres�ss yStreet 'SW Cr�ity jA[y Zip Parcel# <br /> PROPERTY Owner �r Ja :� f ddre5S ' �_—City ZipPhoneii <br /> C-57 Contractor D41 ek Address I�.t' rtd, City �D�,S Zip�ks11 Kett�lf.�7 r1 Phone#70-37V-- <br /> 410- <br /> �-37Y' <br /> Consultant I Sub Contractor �/L�T w rid y Add 3 v*W alk City Ca z/LYi- Lim —Phone# 0"0 7�-0,1, <br /> GIs Coordinates x <br /> Y T�ownshrp' T� Rang eJ� <br /> WORK tO BE-PERF0 !� MiniTRUGTtON(choose type below) <br /> NEW WELL/BORING(CPT GEOPROBE.HYDROPUNCH,BAND-AUGER OTHER") OVER-BORE <br /> ,��r <br /> 13 SOIL BORING# <br /> HELL# I7 PRESSURE GROUT <br /> tout Spec�ficad4ns _ <br /> COMMENTS f II :► r r 1 lL COS �' G <br /> � •rncr�y�,rts ' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Ag <br /> )(MONITORING 'HOL.L.OW STEM DIA OF SOREHOLE Ill 0p mOLTIPLE CASINGS,Q YES )(NO WELL CASING DIA <br /> 0 EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS S L10 KI JJT-YPE ,F CASING O STEEL , PVC 13OTHER_.. <br /> [)VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL � �% TREMIE TYPE TO BE USEo Q AUGERS a HOSE <br /> p Alit SPARGE Q PUSH POINT GROUT SEAL PUMPED ` Yes P No (NOTE. MAXlME1M FREE-FALL DEPTH IS 30') <br /> SOIL BORING [1 HAND AUGER GROUT SPECIFICATIONS n-kfl Ulya } <br /> a OTHER �0 OTHER APPROX.BORING DEPTH �OLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUC,�TG"" R CASING PriOPOSEDI�� --(if(if YFS,list specifications here) N�l <br /> -COMMENTS- AWill � rn ,1iwd,ws. xald v. tT �kl t �Ln I kd vlc <br /> qW n cL , tin rt a '� d � Zct�Z 1rtn <br /> NOTE' OFFSITE BORIN S REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVO NCE FOR ALL REQUIRED INSPECTIONS. <br /> I thereby certify that I have prepared this application and that the work will be done I n accordance with San Joaquin <br /> County Ordinances, I and Regulations, and all applicable California State Laws/ � 1 <br /> Signed x _ 1 ltle/Company 6'p jog iij ( U, 71/77) <br /> 2571,44 E0 <br /> Print Name ✓W t 1 l7,��^St I _Date- _b-o-1 ---- <br /> "DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 25775 11: <br /> WORK PLAN DATED: 15 0 C t-a 5 a 200Z- <br /> Application Avmpted By <br /> 0Z-ApplicationAvmptedBy NJy\ ��v1r��•C�jc/1 Datessued i3 Pr rel �uD'I` Area m53 <br /> Grout Inspection ay Date Final(Inspection By Date <br /> Destruction Inspection By Date <br /> COINMENTS f CONDrnoNS <br /> 0 ACCOUNTING ONLY AIO# <br /> PE COoES ME INFO AMOUNT REMITTED CHECK# RE-CID BY p�TE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3501 �A # 139 ��f5f CN i!� 00 ,31 I`{ Z <br /> C-57 WC___-WATVER— C-57 Letter of Authorization tO $19{1 permit Encroachment dot 9/27/00 <br /> TOTAL P.02 <br />