Laserfiche WebLink
10/2,5/2001 09 33 2094683433 FIFTH FLOOR 101 PAGE 02 <br /> Mo[El 'EDD WELL PERMIT APPLICATION FORM _ SITE <br /> 40 AUG 16 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> ENVIRONW,ENT HEALTH 344 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/%:RVICES (209) 468-3449 rerr• AN <br /> HON-REFUNDABLE PERMrr EXPIRO I YEAR FROM DATE ISSUED <br /> Apphcation is Hereby made to San Joaquin County for a permit to constrict and/or Install the work described This application is made in c rnpriance with San <br /> Joaquin County Deveroprnent Title Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services,Environmental Health division <br /> ff� Assessors <br /> WELL Loptian= tD3� .�; n`Fa ��,Cross Street City Ii�i�I ,r6aAkL z+p9s3�7 Parcel# `( 74-O[ <br /> PROPERTY Owner yQ , f,09 —Address-2-Z.34 .StTo+1 City G-SGul0o1 Zep S Phone# agog�S(k: <br /> C-S7 Contractor G Ega5I�r� _Address q 5-o Bowe RCL city AA!`�i/lgjlip RtiI�T L,crri`IBS1bS phone f4L�393-�$q <br /> Consultant ISub ContractorSi COP- 6102- Phone#fIRI-Q I?6(-0q0C <br /> vo,r 7 <br /> GIS Coordinates X Y ,Township o �� Range,_ F—as+ Section._ 2 <br /> WORK TO BE PERFORMED <br /> KNEW WELL BORING(CPT.GEOPROBE,H �FZZOPUNCH D-AUGER OTHER') a DESTRUCTION(choose type below) <br /> )eSOIL BORING � = [I OVER-BORE <br /> WELL# I]PRESSURE GROUT <br />'Other Grout Specifications <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPE=CIFICATIONS <br /> MONITORING ti [[NO WELL CASING DIA <br />� [[HOLLOW STEM DIA OF BOREIiOLE�R,MULTIPLE CASINGS YES <br /> EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING []STEEL U PVC []OTHER <br /> it H MUD ROTARY DEPTH OF GROUT SEAL_ _65� TREMIE TYPE TO BE USED []AUGERS HOSE <br /> 11 ARGE PUSH POINT GROUT SEAL PUMPED R]Yes [] No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />)OOILBORING (I HAND AUGER GROUT SPECIFICATIONS <br />[I OTHER f)OTHER APPROX BORING DEPTH_ 1(3 5f � [I BOLTED TRAFFIC BOX or l]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list spec fications here) <br />'COMMENTS <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 <br /> I hereby certify that I have prepared this application and that the work will be done In accordance With San Joaquin <br /> County Ordinances, Rules a Regulations,and all applicable California State Laws. <br /> Srjned x Title<Company .S4=C6 Rn�2ir�a'1-zona ZnC, <br /> Print Name 'tr` I'` .10%i;er-lo n i e pate I? '3 O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �� / S Sd­� A- P-01, <br /> WORK PLAN DATED. S— O–4 <br /> Application Aocepted By Date Issued /40 r Area 0600 <br /> Grout Inspectlan By Date Final Inspection BY Date <br /> Destruction Inspection By Date Of <br /> COMMENTS I CON DRIONS_ rG/►'�-�' <br /> NTING OI ILY: AID# <br /> PE CODES FETE INFO AMOUNT REMDTED CHECK# REC'D BY DATE PERMIT/SERVICE REOUI=ST# INVME <br /> C-57 WC WAIVER2 C-57 Letter of Authorization to sign permit�—p Encroachtttent do 9/27/00 <br /> Q�GGu.onr <br />