Laserfiche WebLink
WELL PERMIT APPLICATION FCMM SITE <br /> -� MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 458-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAf2 FROM DATE ISSUED <br /> Application u hereeve o made <br /> meno sari <br /> tle,Joaquin <br /> Chapte C9-1115 3 a dethe Stada ds of Sant to constwct for Joaquininstall <br /> County P described. <br /> ublic HealthThis <br /> Services,plicatn�Environmental Healn is made in th IDiv scion, San <br /> ,toaquin Coun D p Assessor's <br /> va<,hpk•ti�Pi�Y �K'vY X ZiA_Parcel# <br /> WELL Location 07 04DS Cross Stree `_ C'ry P <br /> re 9K-0'Q City orxla Zip Phone <br /> PROPERTY O.vner Address S s v <br /> (� Dr Address City]iJ <br /> C y <br /> C-57 Contractor <br /> Addressly�-��� <br /> ir7y/�Tlc� Ciry�Lic# Phoney�9 <br /> Consultant!Sub Contractor �Z <br /> Y <br /> Range Section_ <br /> Township <br /> GIS Coordinates:X - <br /> WORK TO BE PERFORMED: DESTRUCTION ce-t�a.belo.v) <br /> U NEW WELL 1 BORING(CPT,GEOPROBE.HYDROPUNCH.HAND-AUGER,OTHER') s -,, _ O <br /> []SOIL BORING# - <br /> p WELL# Grout Specifications: <br /> 'Other: <br /> COMMENTS: <br /> TYPE_OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONSULTIPLE CASINGS?a YES WNO WELL CASING DIA: <br /> HOLLOW STEM DIA.OF BOREHOLE--ay- XpVC 0 OTHER: <br /> �jh40NITORING frL -� TYPE OF CASING: �STEEL ..,. <br /> []EXTRACTION AIR HAMN1ERlDRIVEN CASING THICKNESS <br /> VAPOR Q MUO ROTARY <br /> DEPTH OF GROUT SEAL S TREMIE TYPE TO BE USED ;AUGERS HOSE <br /> []AIR SPARGE Va PUSH POINT GROUT SEAL PUMPS Yes o tNOTE.�UM FREE-FALL DEPTH <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS. /ems�C <br /> 0 OTHER: []OTHER <br /> APPROX,BORING DEPTH d BOLTED TRAFFIC BOX or ,�j75TOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (it YES,list specifioakions here <br /> *COMMENTS: <br /> i �y5 :�S AZ/� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT <br /> FCCROACRH ENT PERMITS. <br /> RM G SONS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN A <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances Rupees an gulations, and all applicable California State Laws. r <br /> TitlelCompany <br /> Signed x <br /> GG- Date � - C) <br /> Print Name DEPARTMENT � <br /> USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> f/��� Date Issued 3- 0 Area 43 <br /> Application Accepted By T~ pate Final Inspection by Date�� <br /> Grout Inspection By <br /> y f Date /! OZ <br /> Destruction inspection 8y XM*� <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE 1NF0 AMOUNT REMITTED CHECK# REC'D ZDATEPERMIT SERVICE REQUEST# INVOICE <br /> 0 <br /> C_57— WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> 11q(.7 1 <br /> 9/27/00 <br />