Laserfiche WebLink
02/27/2003 10:09 FAX 209 948067 • 10002/002 <br /> 02/27/2003 06:09 209468 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT-.AP LIGATION FORM SITE <br /> SAN JOAQ IN COUNTY IIrIITIGAnaN <br /> ENVIRONMENTAL H H DEPARTMENT (EHD) <br /> 304 E. Weber, Third Flo r, Stockton, CA., 95202 UNIT IV <br /> (209) 4,168-3449 <br /> NON-RaPUND.MLE P SPIRES 1 YEAR FROM OAT ISSUED <br /> Application Is hereby made to San Joaquin County(ora permit to construct an 'or Install the work described. This nppllcation is made In compliance with San <br /> Joaquin County DeVefopment Title,Chapter 9.1115.3 and the Standards of Sa Joaquin County Environmental He Iin Department. <br /> WELL Location cross _ <br /> Sbeai city to zip P Or.7Z -off.-ora <br /> PROPERTY Omer � Addrawil a��r q I5&97— Phone# /T-y�0 <br /> C-87 Contractor fa ddres C G _ZIpKI&-Li CL Phone# b ��Z <br /> Consultant/Sub Cntr Address Z G City U Phoneff �✓2 <br /> GISCoordinates:X Range_� __�ton /f` <br /> X.Y ,Townshi <br /> WORK TOyy�E PERFORF1Eip� <br /> �l` ,]_�B�GI# (?a GE�TE,HYDROPUNCH,HAND-AUGER,OTHER•) 0 DESTRUCTION (drooee type below) <br /> �n WE^LL# 3 p OVER-BORE. DIAMETER <br /> q'�Othar_SrMUU kf t o, I o PRESSURE GROUT <br /> dlrA GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL iN5iALLATION TYPE CONSTRUQTION SPQIFICAT ONS <br /> t1 MONITORING p HOLLOW STEM DIA.OF BOREHO r r 0 MULTIPLE CASINGS 'p [/f�MULTI-LEVEL WELL CASING DIA: • /�- <br /> 13 EXTRACTION 0 AIR HAMMER/DRIVEN CASINO THICKNESS "r- TYPPE OF CASING: tl STEEL U PVC U OTHER:�� <br /> Q VAPOR 0 MU ROTARY DEPTH OF GROUT SEAL (74 �EMIE TYPE TO BE USED; =RS4eHOSE <br /> 11 AIR SPARGE)OZONE�USHPOINT(GP a CPn GROUT SEAL PUMPED: a No (NOTE: MUM FRE -FALL DEPTH 1830') <br /> L BORING X3 dHANDAUGER CIr l GROUT SPECIFICATION$ t nit yr <br /> OTHER: n OTHER APPROX BORING DEPT ` []BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOS9D <br /> COMMENrS: 0f YES,Sst epecMcations it comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that aveprepegd application and that the work will be done in accordance with San Joaquin <br /> County Ordinan u lie tions,and all applicable California State Laws. / (/ 0 <br /> Signed x `_t// Tide/Company _ -" r,1 ",(C/7-- <br /> Print Name a <br /> DEPARTMENT USE ONLY Oat, <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: (per-, o p <br /> Applicallon Aoeoptad BY -ate" Date Issued9444,16-5 _iA2a 7 1�7 <br /> Grout Inspection BY Date Final Inspection By Date <br /> Destruction Ins action By Date <br /> COMMENT6/CONDITIONS: <br /> ACCOU"NG ONLY: AID# FACII <br /> PE CODES F�INFO AMOUNT RETOTTED CHECKS RECO BY DWT[ PERMR/SERVICE REQUEST# INVOICE <br /> 3�J 7 6s� z3 sR#�o3�-77? <br /> C-57 WC--WAIVER— C-57 Letter of Authorization to Sign permit_Encroachment doc_ 9/30/02 <br />