Laserfiche WebLink
Apr . 29 . 2002 4: 17PM CONDOR EARTH TECHNOLOGIES No . 9363 P . 2/6 <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., 95202 <br /> (209) 4683449 <br /> NQN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application Is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 ano the Standards of San Joaquin County Public Health Services,Environmental Health Division, <br /> pw�Il� lA;eYk S R4' k,}Of WO-44 Assessors <br /> WELL Lac bort(Wr'tb+. CJtrlb&J, M�r.,iir yr!�+oss Street City +o,(n +cy% Zip`12a�Parcel#f <br /> µIi✓' <br /> PROPERTYOwner FL4blike- WGrkS Address City Zip Phone# <br /> *� ! <br /> C-57 Contractor ��q J»H S>+kA Addross�SO f o ul t Ii;.d� City s �A&-&Zip j4S53 Lie -Jglf Phone#9 LV- 00 <br /> twen�/!r <br /> Consultant/Sub Contractor 1,"kK0710 wl�f� �• Address 5'�/_ CitySlroc eN LiC# Phone#,Z0%-7-'54-05J <br /> GIS Coordinates:X Y--- Township Ranye Section <br /> WOIC TO BE PERF MED: <br /> EW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER") a DESTRUCTION(choose type below) <br /> aOIL BORING# OVER-BORE <br /> WELL# (]PRESSURE GROUT <br /> 'Other: Grout Specifications.- <br /> COMMENTS: <br /> pecifications:COMMENTS: <br /> TYPE OF WrFLL INSTALLATION TYPI; CONSTRUCTION SPECIFICATIONS <br /> t1 MONITORING (I HOLLOW STEM DIA_OF BOREHOLE 2. MULTiPLE CASiNGS7 n YES 9<0 WELL CASING DIA: <br /> 0 EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS X1 A', TYPE OF CASING: p STEEL H PVC [JOTHER: <br /> a VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL NA -TRF-MIF-TYPE TO art USED: U AUGERS WI OSE <br /> n AIR SPARGE PUSH POINT GROUT SEAL PUMPED: ees a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> VISSOIL BORING []HAND AUGER GROUT SPECIFICATIONS- <br /> a OTHER:_ReOTHER �f''I- APPROX.BORING DEPTH F Z d' O BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED7 N b� .-(if YES,list spec ificatlons here): <br /> COMMENTS: Q�a:.4 _ I v�Vl�ctnlMRv► "ell_ 5i�� p1»t �tv�� C,?T* b4t!i�4 f eV%C_raa��v►wa.v�t <br /> .A.r vin.�'i- cr�l.alrL.�v� • M '_� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT 1V INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <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 and Regulation and all applicable California State Laws. <br /> Signed x r ,_Title/Company <br /> Print Name ,D i'IV - Date—1�� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS! <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued _Area <br /> Grout Inspection By „„ __Date ___ _Final Inspection 8y Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AM�FRFMITTFDjCHtFzCtK# tREC'D DATE PERMIT 15ERVICE RI`QUEST# INVOICE <br /> _� _ <br /> a/,)-7 nn <br />