Laserfiche WebLink
05i 03/2001 09:52 2091683433 FI=TH FLOOR PAGE 03 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95242 <br /> (209) 468-3449 <br /> NO114d FUNVARM 111111111111 EXPREO 1 Me FRAM DATE IS'U D <br /> 3ppcaticn is hereby made to San Joaquin County for a perk to construct and/or Irrslall the work described. This application is made In cumpAance with San <br /> quln County Development Title,Chapter 9-1115.3 and the Standards of SanJoaquin County Public Health Saalcm.Environm g1 HeaIC DMS• <br /> _LL LoG.1ron450f3 �e Nar1a►n CrossStreetl�. Jr�111N ZIo 3� Paroel# l9?x�llOb?� <br /> eOPERTY Owner Addrers q50 � Harlan t ty Ft Z}p95►�31 Phoneli <br /> 7 Contractor Prec fission Samp{�Address NW S. 5dS}rCC� City h and ZipUd1�'5 phonelf 5�3} r`,�4�4F <br /> onsuhantISub contractor[�tCtLn �LxCll►CC1� AddnasslbZ3S Val fft1QA CItY II�� V Fhon `ri `fu70 <br /> Coordinatew-X 'Y- Towrm* Range Suction <br /> dORK TO ISE PERFORMED: <br /> NEW WELL 1 BORING(CPT EOPR HYDROPUNCH,HANG-AUGER,OTHER') DESTRUCTION(rlroosv typo ibelow) <br /> SOR.I30RING11 "rr'YrAI (�F _ QOVERBORE <br /> 0 WEPRESSURE GROUT <br /> utter: Grout Spacdi�aE+uns' <br /> :OMMENTS:TorAt- n,� 5 iia atamx - <br /> UcxfiLll wtn� �A - -_ ��iy►�T, <br /> PE OF VALL INSTALLATION TYPE coNIMUCTION§MIFICATION1. <br /> I MONITORING 13 HOLLOW STEIN DIA.OF BOREHOLE MULTIPLE CASINGS?I]YES 0 NO WELL CASING DIA: <br /> SX-TRACTION D AIR H MMER/DRNEN CASING THICKNESS TYPE OF CASING: (1197EEL 0 PVC p OTHER <br /> VAPOR 13 MUD ROTARY DEPTH OF GROUT SEAL —TREMIE TYPE TO BE USED: i3 AUGERS Q HOSE <br /> AIR SPARGE I]PUSH POINT GROUT'SEAL PUMPED: I1 YOU, 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301 <br /> ]SOIL BORING 1)HAND ANGER GROUT SPECIFICATIONS <br /> OTHER: []OTHER APPROX BORING DEPTH 0 BOLTED TRAFFIC BOX or I]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (If Vag,Mgt spgdncatlons herek <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UN1T N INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> lereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> ounty Ordinances, Rules and Regulations, and all applicable California Stgte Laws. <br /> autd Recilb4 rl -C-&-MP Ing �— Ca.idyl) <br /> Dred A r� N, LLC r�ec&mpany ) J <br /> int NamA I,,,e �i/ZQ. � L7 _Date �[ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADD ES : 5 <br /> WORK PLAN DATED: 3 3o D <br /> pplicalion Accepted By <br /> ` Date issued �•3 Area <br /> --i <br /> Grout Inspection gy Qate Final Inspection By Date <br /> ,pestruction inspection By Date <br /> 13MMENITS I CONDMNS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMQUNT REMITTED CHECK* REC'D BY DATE PERMIT/SERVICE REQUEST INVOICE <br /> Sul &jD3 <br /> Encroachment dac____ 9/2710D <br /> "-57 WCC WAIVER C-57 Letter of Authorization to sign permit_ <br />