Laserfiche WebLink
01 / 19/ 2001 16 : 05 20946034 '• ' FIFTH FLOOR PAGE 02 <br /> WELL 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 -3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> plirallon 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 /> aquin County Development Title, Chapter 9-1115-3 nd the Standards of San Joacuin County Public Health Services. Environmental Health Division. <br /> Gl7Y ap ' Assessors <br /> _LL Location .3>D /%�//,r,I� a41 njssStreet City �+ � Zip 9521 Panxl# <br /> tOPERTY Owner 4;;; O /g`" `/ JM Address / L�y � � '� grCib/�C/llC� � Ziphone# - <br /> 57 Contraclom�r 7 Ai - !//1/k/t�N Address Ay �G �// z Cih � ZIP �Lic# 7�7.5� Phone# <br /> tnsultant l Sub Contractor /'7`' ss k7 /�1lo.GL �1J Cdy ' Lic# Phone# P 8� �p voe <br /> 'S Coordinates: X., Y , Township Range Section <br /> ORK TO 8E PERFORMED: <br /> NEW WELL / BORING ( CPT, GEOPR065, HYOROPUNCH, HAND-AUGER. OTHER•) [) DESTRUCTION[)( hoose type <br /> below) <br /> OVER-BRE <br /> G SOIL BORING # <br /> ❑ <br /> WELL # � `f' H% � PRESSURE GROUT <br /> Ither. Grout Specificatlons: <br /> OMMENTS: <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORI HOLLOW STEM DIA, OF BOREHOLE � ��j� <br /> �� MULTIPLE CASINGS? 0 YES NO WELL CASING DIA: Z <br /> eXTRACTION [LAIR HAMMPPJDRIVEN CASING THICKNESS ! TYPE OF CASING: O STEEL APVC [) OTHER: <br /> VAPOR [) MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO SE USED: GAUGERS [) HOSE <br /> AIR SPARGE [) PUSH POINT GROUT SEAL PUMPED- n Yes n No (NO E: MAXIMUM FgE&FALL DEPTH IS 301 Q <br /> SOILBORING [) HAND AUGER GROUT SPECIFICATIONS- <br /> OTHER: [) OTHER APPROX. BORING DEPTH D � uOLTED TRAFFIC BOX or [] STOVEPIPE <br /> CONDUCTOR CASING PROPOSED?_ ( If YES, list specifications here)- <br /> COMMENTS: D Svc" c 6 %0 <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 /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> 3ounty Ordinances Rules <br /> and <br /> Regulations, and all applicable California State Laws. <br /> 1246 <br /> 3ignsd xxi ,s/_�% ' �9� / Tide/Company . - <br /> =rim Name -- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: � I <br /> / yyII <br /> Datessue <br /> Id Lr. fo AreaCJ�` .J <br /> Appllcation Accepted By tkk <br /> Grout Inspection By <br /> Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS ! CONDITIONS- <br /> ACCOUNTINGONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS RECD BY DATE PERM R 1 SERVICE REQUEST # INVOICE <br /> C-57_ WC=WAIVER_, C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/ 27/00 <br />