Laserfiche WebLink
jl <br /> WELL PERMIT APPLICATION F6l4m <br /> SITE <br /> � Q TION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> UNIT A <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Tti1ird Floor, Stockton, CA., 95202 <br /> _ W 1(209) 468-3449 <br /> NON-REFUNDABLE ERMIT EXPIRES 1 YEAR FROM DATE ISSUED y <br /> Application is hereby made to San Joaquin County for a permit to c6nstruct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> V -'r r� - 'f�/ / 1') n I) Assessor's ? <br /> WELL Location L� 1'-I _ - `�C:j Cross Sltreetl' Gn111n? '�r�d nII�� City roc � Zip 53X, Parcel#ZSD -da0-�7- I <br /> Pi <br /> ROPERTYOwnervtiC. � '�('• Address a,qo I0pCirypJ C Zip r�Phone<2P� �f1�$ 6S1�.7 <br /> C-57 Contractor 'I Address (750 �W I Q QC� Cityy fez zip Lii:A 6> Phoneif( !-S/3 <br /> I � p _ (� /,1,olfl l <br /> Consultant/SubContractorl-IaUQPIC C 62,6,70 Address Si37 G,caJ Ciry Lica hone# � `f67-/UV6 r <br /> ` , <br /> GIS(Coordinates:X ,Y III,Township Range-Section <br /> nD <br /> 11I TO BE PERFORMED: �� p <br /> EW WELL/BORING(CPT,GEOPROBE,HYDRO P}�NCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> y SOIL BORING# O� q 6 2001 0 OVER-BORE <br /> 2 j <br /> - BWELL# If FEB BPRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS FN\/IRf1NMFNT HEALTH - <br /> II' PERMIT/SERVICES <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLEIt MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:_ <br /> EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> B VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL EA`FI�- TREMIE TYPE TO BE USED: .j S 0 HOSE <br /> Q AIR SPARGE GUSH POINT GROUT SEAL PUMPED: 0 Yes A-&o (NOTE: pMAXXII/MUIy� FREE-FALL PTH IS 30') <br /> *SOIL BORING BHAND AUGER GROUT SPECIFICATIONS: q C: r6rTTGNd� -)o 6Gul�onS 1.� <br /> a OTHER--fl OTHER APPROX.BORING DEPTHd 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> i 1, CONDUCTOR CASING PROPOSED(if YES,list specifications here): j <br /> I <br /> COMMENTS: <br /> jl! <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 /> 1 hereby certify that [ havepreparedthisapplicatic In and that the work will be done in accordance with San Joaquin <br /> County Ord' nces, Rules a egulations, and all applicable California State/ 6- <br /> Laws. /p <br /> Signed x_ /L 4A Title/Company �l a"CR" - //Orri /.3 <br /> p <br /> I <br /> Print Name D6 <br /> DEPARTMENT USE ONLY <br /> (SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: n ) ) Cm <br /> Application Accepted By I. Date Issued -z' /�`"'p / Area <br /> Grout Inspection By (/�r��N��r= - ADate Final Inspection By (��AA&rw, Date <br /> 'i Ij 11, !l/L <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: I <br /> ACCOUNTING ONLY: AID# II <br /> PE CODES' FEE INFO AMOUNT REMITTED CHECK# <br /> 35 RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> n1 X9. 00 �{ 3 � e �o sHz <br /> C-57_ WC--WAIVER C-57 Letter of lAuthorization to sign permit-Encroachment doc_ 9/27/00 <br />