Laserfiche WebLink
02/27/2003 1.0:09 FAX 209 94806 C�JO(12/0(12 <br /> 02Y27/2003 08: 09 209468 FIFTH FLOOR • PAGE: 02 <br /> WELL PERMIT-.AP LICATION FORE41 SITE <br /> SAN JOAQL IN COUNTY MITIGATION <br /> HEAL H DEPARTMENT (EHO) <br /> 304 E. Weber, Third Flo r, Stockton, CA., 9520: UNIT IV <br /> (209) 8.3449 — --- <br /> NON-REFUND BLE PERMIT IRES 1 YEAkFRPM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct an or install the work desodbed. This epplicatinn is made In compliance with San <br /> Joaquin County Development Title,Chapter 9.1115.3 and the Standards of Sa i Joaquin County Environmental Health Deparment. <br /> �^ T AA0 <br /> Assessors <br /> WELL Locaeon E D A- CroCity Zip — <br /> PROPERTYOwner .,{ AddresC7 y 4-zip��J�Phone#A17-171r��& <br /> AU:C•57 Contracto /�W/G/� AtldresZIAJml VL " f 7�c/ /Consukam I Sub Cntr d //.lCiAddressCity.�Lic#GIS Coordinates;X ,Y Range_ __ Sectlon! <br /> WORK TO BE PERFORMED: <br /> .XNEW V1 ELL/BORING (CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DIESTRUCTIOVII (choose type balovj) <br /> IL BORING# 62.-5 3 DOVER-BORE. DIAMETER_—__ <br /> n WELL# 0 PRESSURE GROUT <br /> q�Other_5,ttut k1 e ern I GROUT SPECIFICATIONS <br /> COMMENTS' ----- <br /> TYPE OF WELL INSTALLATION TYPE CONST UCTt N P IFICATIONS / <br /> Il MONITORING a HOLLOW STEM DIA.OF BOREHOLEEr r p MULTIPLE CASINGS -p MULTI-LEVEL WELL CASING DIA: <br /> p EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS W TYrrP^-E OF CASING: n STEEL Q PVC 0 OTHER:. <br /> OVAPOR 0M�UD ROTARY DE PTH OF GROUT SEAL�-�u UfTrfeIEEMIE 7VPE TO BE USED: pd`�'Lrp �-�10SE <br /> U AIR SPARGE/OZONEorPUSH POINT(GP or CP7I GROUT SEAL PUMPED: 0 N,to (1�®T E. MU FREE-FALL DEP�1 IS 30') <br /> �,SfJ�BORING X�j n HAND AUGER L X ( GROUT SPECIFICATION$ 1. u1.! V <br /> OTHER: 0 OTHER APPROX,BORING DEPT 20' r L 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOS ❑ _(f YES,list spec}9rations in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMI I':. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPEECTICINS. <br /> I hereby certify tha;4rave prep ed t s application and that the work will be done in accordance with San Joaquin <br /> County Ordinan EC�u a Ree$ tions,and all applicable California State Laws. /_ <br /> Signed `-[/ TitlelCompany _ �� S,-t('_ r'.d TC A.,�_�" <br /> Print Name / rq Ail2lzznote--'o�� L 0. <br /> ' DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By ♦r'rt A-411-0 Date Issued LI 4, <br /> Grout Inspection By. Date Final Inspection Sy _._,Date__.__ <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: �— <br /> ACCOUNTING ONLY: AID# FAC# _ <br /> PPrzRy <br /> CODES FEEINFO AMODUNTREMITTED CHECK# REC'[D SY DATE PER '#M71SERVICEREQUESTINVOICE <br /> C-57 WC -WAIVER, C-57 Le't'ter of Authorization to sign permit_,I'ncrouChrllent clot_ 51/710/02 <br />