Laserfiche WebLink
WELL HERMIT APPLICATION I={„:M SITE <br />MITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT ISI <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct 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 />Assessor's <br />WELL Location ZO8.S FAZE ST, Cross Street `AUACL City S''7o-cJc>6A/ Zip Parcel# lyl'11z-o3 <br />PROPERTY Owner J'"ERI FoPPIANo Address ZJifo PkLrhS1ct-7rAlNCCiritySr'oCt-roN Zip 20 Phone# 9.?3 `7.T Z3 <br />C-57 Contractor 1j9 oo-b W AooW Address P.'O. BOX 3 3 5;� _CitY Ja VI ,r-74 Zip'yk7/ Lic# Oo7 Phone# la7 2 V3206 <br />Consultant/ Sub Contractor 4 rC /iSSoCrA'T6 s Address // / 7 LofJ E PAL N) Cityeft'k S ro Lic# Phone# <br />GIS Coordinates: <br />Towns <br />Rang <br />Section <br />W0113K TO BE PERFORMED: <br />EW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE <br />0 PRESSURE GROUT <br />�NELL # 7WE44S <br />'Other: Grout Specifications: <br />COMMENTS SEG w14r woA4,0GAsJ REVIaE� .3 3ZZDf/ 4 ig MC ---I,. / oS/ <br />SPECIFICATIONS <br />TYPjE OF WELL INSTALLATION TYPE CONSTRUCTION <br />JO WELL CASING DIA: <br />ONITORING W OLLOW STEM DIA. OF BOREHOLES MULTIPLE CASINGS? 0 YES <br />a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSSCe Ya TYPE OF CASING: 0 STEEL 2-OVC 0 OTHER: <br />U1 <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL V Aje!"LE TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: g-' es 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br />s-l1S g�30LTED TRAFFIC BOX or 0 STOVE PIPE <br />OTHER: [] OTHER APPROX. BORING DEPTH <br />0 14PPROX <br />CONDUCTOR CASING PROPOSED? A_ ( if YES, list specifications here): <br />`COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING <br />I hereby certify that I have prepared t s application and that the work will be done in accordance with San Joaquin <br />County Ordinances, es and Re fations, and all applicable California State Laws. <br />Signedx Title/Company 6EoGo!-�/Sj �TC /4SSoCI,4r6 <br />Print Name � �� �`% V C _Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 6 o A � kms, <br />Application Accepted By cel Date Issued it S /O `� Area L� <br />Grout Inspection By <br />Date I I O Final Inspection By 1�-. ��r^ Date t i l o <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: N tC / C <br />r <br />ACCOUNTING ONLY: I AID# <br />PE CODES I FEE INFO I AMOUNT REMITTED I CHECK # <br />,2 <br />RECD BY I DATE I PERMIT/ SERVICE REQUEST # I INVOICE <br />3 S-()1 " O 0 1 � �o6 I t,(-( I 116f cY I S R# `t O z -q- �( <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />