Laserfiche WebLink
U/02/2001 09:27 20946$3433 FIFTH FLOOR rrauc u.+ <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAW JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EH.D) <br /> 304 E. Weber, Third Floor, Stockton, CA., 9-6202 <br /> (209) 468-3449 <br /> NQN REFLINDABLE PERMIT EXPIRES 1 YEAR FM D <br /> ROA 15SUED <br /> ?ppcation is hereby made tO San <br /> eJoa quina County <br /> f 3 and.thel Standards of San Joaqt to c,;nstruct and/or u nl County Public Heal Servithe worh described. Thi5 ces,I-nvkonmental Health cation is made in compliance <br /> San <br /> a^ in County Development Pl Assessor's <br /> e� ZI P=&W <br /> E Location Cross street mss}' Gly , 1<r� P <br /> • Cily prJphone# ' <br /> ROPERTY OwnerDj C% 'fr`''t 5 Address b31.3 �P �/a <br /> 8 ( 237-4375 <br /> rrt'G�$ip✓i S 1 Address !� _Zp <br /> Clty <br /> 98x ` honetf <br /> convactor rhone# /g/a �d$_3 3 0 <br /> onsultant l Sub Contrador I T Gra i^� Address 3 <br /> $.ic�s.•w Idf_ <br /> ge Section <br /> it :oord`nate6yX '�7 04y ! 1°�o So 3 Township <br /> L–aYc�cc P�.cGt f <br /> ��(TO g PERFORMED_ .------ d DESTRUCTION(Choose type below) <br /> `NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER'? [�OVER43ORE <br /> p SOIL BORING 0 PRESSURE GROUT <br /> O WELL Grout Specificadans: /J <br /> 0,;? <br /> :.OMMENTS: <br /> r EWELL INSTALL_A_j N TYPE CONSTRUGTIO SPECIFlCATION$ <br /> HOLLOW STEM DIA OF BOREHOLE� •• MULTIPLECASINGS7 0�S ONO WELL��D�'' <br /> mONiTONNG 0 CZ k TYPE OF CASING, CI STEEL G PVC I1 OTHER: <br /> =XTRACTION O AIRµAMMERIDRIVEN CASING THICKNESS <br /> APOR< p MUD ROTARY DEPTH OF GROUT SEAL <br /> 20 Ft- TREMIE TYPE TO BE.USED:, (]AUGERS Q HOSE <br /> ROUT.SEALPUMPED: Oyes Iia (NOTE: MAXIMUM FREE-FALL:DEPTH !S 3(1') <br /> •,RSP_ARGE 3(PUSH POINT G <br /> p SOIL BORING 0 HAND AUGER GRAUT SPECIFICATIONS: <br /> [ <br /> APPROX.BORING DEPTH BOLTED TRAFFIC BOX 'or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOS�? o; <br /> (ff YES.list Specayns ohere <br /> THER: OTHER _. <br /> *COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT <br /> NCROA ALL REQUIRED1NSPE TS.' <br /> GALL THE UNIT N INSPECTOR 48 WORKING HOURS IN A�VAN <br /> cert, that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> lereby ifs hcable California State Laws, <br /> l'ounty Ordinances,Rules and Regulations, and all app <br /> Aft c k o�,�5 � TitlelCampany <br /> Inad Date <br /> int me DEPARTMENT USE ONLY <br /> ITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> � of Area_fs� <br /> Date issued Dates <br /> pplication Accepted Y_4� Final Inspeckn By <br /> Date <br /> Grout Inspection By <br /> estruction Inspection lay Date ei 77 a Z <br /> OMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID#, <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK� REC'D BY DATE PERMIT 1 SERVICE aEnuEST 0 INVOICE <br /> L 6� 00 <br /> p ►•�/ 7 ! _ _ _._ ___�:� r.nernnrhmen doc— 9127100 <br />