Laserfiche WebLink
10-24-2000 03 40PM FROM APR 19 2004 TO 15306766005 P 02 <br /> Awk PyWELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-34491 1 <br /> 468-3449111 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appricativn is hereby made to San Joaquin County for a permit to construct andlor install the work descnbed This application is made in complsanCe with Sen <br /> Joaquin County Development Tift Chaprwf, <br /> r 9- 1 5 3 and the Standards of San Joaquin Co city Public Health Services,Environmental Health Division <br /> r,?I�IJI� 5T-5'3� a� z, P ��y <br /> I"- <br /> WELL Loeatlo + �� Cross Street Ity a P <br /> PROPERTY Owner I �} Address 1 ��U:TW lCr,ty SCJ 1 Zip_-1 �Phcnef_ <br /> C�67 Contractor AtT }�!i t n �CAddrisss 5 ( +y r6v"�f C U, Zip r�/ l i !�t?p Ptlorte ��0y7'3 - C7 <br /> Consultant!Sub Contractor, <br /> � r Flld Address33yr0 CsJr„bscn/�. 1�i Ci rftiY�7!-)Lim yS6z 1'hone#F J�('671s ZOloz <br /> ip .r Range Sectio <br /> G13 Coordinates X Y,,Townsh <br /> YY RK TO E 1: EFMARIMLD <br /> EW WELL/BORING(CPT.GEOPROBE HYDROPUNCH,HAND-AUGER OTHER') R DESTRUCTION(choose type below) <br /> 0 SOIL BORING# Q OVER <br /> -BORE <br /> # � Q PRESSURE <br /> ORE <br /> URE GROUT <br /> "Othor Grout Specifications <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> AMONITORING ',HOLLOW STEM DIA OF BOREHOLE U v1 M LTIPLE CASINGSI©YES ]]NO WELL CASING DIA. _ <br /> a EXTRACTION p AIR HAMMERfDRN-EN CASING THICKNESS5- ti 'TYP E OF CACA SING STEEL BE Vf VC BOTHER <br /> Q Al1GEF2S HOS>* <br /> �a VAPOR 11 MUD ROTARY DEPTH OF GROUT SEA I C.✓;t TR <br /> []AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED *Yes Q No {NOTE: MAXIMUM FREE-FALL DEPTH IS �0') <br /> 0 SOIL BORING HAND AUGER GROUT SPECIFICATIONS 2d uouid <br /> a OTHER_O EI OTHER APPROX-BORING DEPTH j <} ice' *OOLTED TRAFFIC BOX or 13 STOVE PIPE <br /> CLbNDUC OR_CJASING P POSE ' (IO (if YES,list speofications here <br /> -COM ENT W ��5 LL's I•t L ��'lrt�cr� I get d c�:n r /V ►r" j� <br /> le <br /> NOTE OFFSITE BORING 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 wor� will be done In accordance with San Joaquin <br /> County Ordinances,,�2u� s and Regulations, and all applicable Cahfomla State Laws <br /> I J� TitlelCampan� r �J't+t7,7y�+ 57rr� �N✓i � ', <br /> Signed x r �Z �� <br /> Print Name DEPARTMENT USE ONLY Rate <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_ 25-775 S c-P&I <br /> WORK PLAN DATED: ?5 pct-<:-, 200 <br /> `` 'u { �ev40eCC�VL Date ssued L)u I13/0 y Area /ys <br /> Application Accepted By,- L R v -— - -- <br /> Grout Inspecton By pare — -Final Inspection BY <br /> Destruction Inspectuon By Date <br /> COMMENTS I CONDITIONS <br /> Afth ACCOUNTING ONLY A100 qW <br /> -� <br /> PE CODES ME INFO AMOUNT REMPTTED CHECK# REC'j,,, j p TE RERMrr 1 SERVICE RE4U>=s-r aR INVOICE <br /> 350 / /UJ LTJ ,9 �"1�5'y CN <br /> permit Encroachment d <br /> C-57� WC -Wa1V>;R„_._ C-57 L+gtfier o Authorization to sig oc 9/27/00 <br /> TOTAL P 82 <br /> I <br />