Laserfiche WebLink
08/0i/2000 11:16 2094683433 FIFTH FLOOR <br />WELL i-tRMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM CATE ISSUED <br />:ciication is hereby made to San Joaquin County for a permit to construct and/or instalt the work described. This apptication is made in compilantei,virh San :acuin County Development Title. Chapter 5-1115.5 and the Standards of San Joaquin County Public Health Services, Environme.ntal Health Division, <br />Cross Street City Zip95) <br />_ <br />Parcel# <br />,--2 -17 /. Assessor's <br />RCPERTY Owne <br />-57 Contractor <br />I WI <br />h100911,114.1 Wiotf-e).5 nto-7 E 10Th S461 city Tizqj Li.4150) iel# onsultant / Sub ContractorW03 <br />IS Coardiriatas: X Y . Township Range Secton <br />ORK TO BE PERFORMED: <br />1. <br />PAGE 02 <br />y) 5 <br />SITE <br />MITIGATION <br />UNIT IV <br />ELI. Location 9 w <br />Address) T(Itti) L,cT rq o q53A Phcziett 3),- (19(00 <br />Addr„Ot 2;6/.1d j Cltv )thil Zip 94`1 Lic#(57-720huno(q 7 77-91GO <br />'y NEW WELL /BORING ( CP . EOPROBE. HYDROPUNCH, HAND-AUGER. OTHER-; <br />SOIL BORING # <br />WELL # <br />OMMEIT7S: <br />a DESTRUCTION (choose type below) <br />0 OVER-BORE <br />Ii PRESSURE GROUT )ther: GROUT SPECIFiCATION <br />ME OF WELL INSTALLATION TYPE <br />MONITORING fl HOLLOW STEM <br />EXTRACTION 0 AIR HAMMER/DRIVEN <br />VAPOR 1UDROT Y <br />A P SPARGE PUSH POINT <br />ORlG 7,1.j a HAND AUGER <br />OTHER: U OTHER <br />CONSTRUCTION 5FECiFicAT1oNS <br />A. OF SOREHOLE 2 it MULTIPLE CASINGS? YES fl NO WELL CASING DIA4 <br />CASING THICKNESS *TYPE OF CASING,: a STEEL a PVC a OTHER: <br />DEPTH OF GROUT SEAL TRENtlE TYPE TO BE USED: 0 AUGERS OHOSE <br />GROUT SEAL PUMPED: )(Yes (NRTE: MAXI UM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATION <br />APPPCX_ BORING DEPTH 2-6/ BOLTED TRAFFIC SOX or a STOVE PIPE IJIA" <br />CONDUCTOR CASING PPOPCSED t3b (if YES, list speccations here): <br />OMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />iereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />aunty Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. <br />* CALL HE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FO ALL REQUIRED INSPECTIONS <br />LPL/4-pvt-e.1)-- <br />/ <br />Title/Company 01/ '—)IkeS 11 ten 6,1 (Dr, otenia red x <br />Oats <br />SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED <br />DEPARTMENT USE ONLY <br />::.otication Accepted By <br />rout Inspection By Date <br />?str-ction Inspection By Date <br />Date issued 4 / / Area <br />Fine( Inspeclon Sy (ALektAr,--- Date <br />tnt Name J r) <br />DMMENTS / CONDITIONS: <br /> <br />A OCCLi NTING ONLY: AIDF <br />311 CODES FEE INFO AMOUNT REMITTED CHECK # i REC'D BY DATE PERNISERVICip-R NVOICE <br />i:-I )3- ‹.59 00 i --i'lvit, BR* 3 :,k t, i , I <br />C-57 WC/WAIVER 7/17/00 C-57 Letter of Authorization to Sign permit Encroachment doc