Laserfiche WebLink
ORIGINAL WELL PERMIT APPLICATION FORM SITE <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County <br />Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />bot hood, Assessnr:g WELL Location Mal" PaC , i`C. 4 <br />Ro <br />t; t. Cross Street b ii- City SI:0c I:toil Zip ci 5 2 07- Parcel# /02 <br />PROPERTY Owner sto)i.e. Address 5308 Ri p ic.c A Ve CitySt0C-ktOrk Zip 95<W7 Phone# 20 052 -C.27-7 <br />C-57 Contractor Gi,e3 ,, Dr:I Iii r,../j Address 950 Holtie Rd Cityil ar't I rimpT•15-6.3 Lic# 650 /6 7Phone# ?a7 5/313 - 5806 <br />Consultant / Sub Contractor /..1-r)11( rt, livelevitt I 4yeltddress iexo 4 (..)itc jo LeCity P/Qce,tt;Lic# 66263(t9Phone# 7/6//4 3;1 • S. _Co/ / <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORM <br />NEW WELL / BORING GEOPROBE, HYDROPUNCH, HAN -AUGER, OTHER*) <br />KSOIL BORING # C. pr- 0 DESTRUCTION (choose type below) <br />DOVER-BORE fl WELL # 0 PRESSURE GROUT *Other: I I <br />COMMENTS: i I ef,F Mu! Grout Specifications: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE e z, MULTIPLE CASINGS? 1:1 YES NO WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL '13) TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE KPUSH POINT GROUT SEAL PUMPED: 1 Yes Ei No (NOTE: MAXIMUM FR E -FALL DEPTH IS 30') <br />$ SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Lielkir- <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 1,50 II— 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications 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 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br />Rules and Regulations, and all applicable California State Laws. <br />Signed x W-7VVLQ.L...a.e Title/Company &-t/V-c,te <br />Date <br />DEPARTMENT USE ONLY <br />I ---, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />UNIT IV ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />NOV 07 2L 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 ft <br />CPT- /1/4-4-W " ENVIRONMEITI <br />Print Name Orenr H -rn <br />SITE MAP IN UNIT IV FILE, ADDRESS: 5-4' <br />WORK PLAN DATED: /0•JtAi4J. 0/ <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Wi") yft4-e — P-6 -0/ <br />Date Issued //-• /3 -0 / Area 6 (P51 <br />Final Inspection By Date 72z, Date <br />Date <br /> <br />rte.41 <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE P Rmtmi sPRVICF EQUEST INVOICE <br />1/2--(a ac,.. /1-7- 1 sR# D02430?tt <br />C-57 Letter of Authorization to sign permit 9/27/00 - -WA