Laserfiche WebLink
12/29 00 FRI 14:36 FAX Z 003 <br /> 12/29/2000 13:36 209468' '3 FIFTH FLOOR PAGE 04 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN jOAOUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH Q}VISION (PHS-EHD) <br /> 304 E- Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 -444 1 G�7 [� <br /> N 0-5 <br /> NDA <br /> tIIItT E[PIRE51 YEAR F T `o o 1 i —3 1 <br /> Application t�reby made to San Joaquin County for a peemit to mnSWGt andlor install the work dtaLrlbcd- Th application is made in cernPliance with San <br /> ,l,KOI cousriy Deveiop,?*nt'tite Chapin►4-1115.3 and the Standards of San Co ub�l'H lh rvices,Environmental H�rx sblvplslon. <br /> �u S ross Street <br /> W 21p Parcel# <br /> WELL L�tian C Q <br /> dress O SIitr ZIP Phone# �3� ! <br /> PROPERTY Owner ,,JJ 31f! <br /> C-57 Contractor <br /> Add C'ty fp Li0i1 �T -7 <br /> Consultant!5ub Contractor sass <br /> GIS Goordinatas:7t •Y <br /> Township Range Section, <br /> WORkIT09.1113111 PERFO h{ED p9STRUCTION(Chooa.NPe below) <br /> Eyy vuELL!BORING([PT.GaOP420BE.HYDRoPUNCH•HAND-AUGER,OTHER') I] a OVER-BORE <br /> [I SOIL BORING# 0 PRESSURE GROUT <br /> 0 WE"P Grain$pect5cations: <br /> -ather- <br /> COMMENTS: <br /> SYPE OF WEL!_ AL t5M TYPE GONSTRUC N S N <br /> MONITORING �OLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?p YES 17�0 VcLL9 OTHER CASING lA�_ <br /> 0 EXTRACTION 0 AIR HAMMI<RlDRIVEN CASING THICKNESS TYlPE OF r-ASIEMIF G: p STEEL <br /> �VAPOR U MUD ROTARY DEPTH[3F GROUT SEAL�(�.�TREMIE TYPE TO t3E USED: p ANGERS []HOSE <br /> 0 AIR SPORGE 0 PLISH POINT GROUT SEAL PUMPED: 0 Y8s 0 No (NOTE: MAXIMUM FRET;-FALL DEPTH 15 3D') 0 <br /> U SOIL BORING p WAN0 AUGER GROUT SPECIFICATIONS <br /> OTHER AppROX.BORING DEPTH p t30tTED 7FtgfFIC 90X or STOVE PIPE <br /> DTIiEFC: I} it YES,lists ciricoons here); <br /> C(]NpUCTOR CASING PROPOSEQ.7 e <br /> I p <br /> -GOMPAENTS: <br /> NOTE: OFFSITE BORINGS REOUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNfr N INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify t I have prepared this appileation and that the work will be done in accordance with San Joaquin <br /> county Ordina , Rules InIFtegulatignS,and all appiloable California State Laws. <br /> TrgplComptlnY <br /> Signed X bate 7 <br /> Print Name PpRTMENT USE ONLY <br /> AP Al j9Y - r3o- 0. oaf <br /> SITE MAP IN UNIT IV FILE, ADDRESS: s � <br /> WORK PLAN DATED' 2 D DL <br /> f f <br /> Date issued I �'1�[0 D Area � <br /> Application Aceoptad 5- p®!e <br /> Grout Inspection By <br /> Dau Fnal Iflspeetinn Ily <br /> Oestruaiian Ins eouon 6y Date <br /> AV- <br /> COMMENTS I CO9IDITtpN5; S LW-j �+^ <br /> ACCOUNTING ONLY: A10" <br /> PE GOD>`5 FEE INFO AM4NN7 REMRTEt3 CyEC![$ tiEC'A BY PATE PERMIT!g(;RVIGE REQUESTS lNVO10E <br /> �-1-e1 9 t- 81- fl dbs ,�K r Moo tOO2, �5-3 <br /> C-57— WC--WAIVER— C-57 Letter of AtlThorization to sigh permit—Encroachrnen# doc� <br /> 9/27100 <br />