Laserfiche WebLink
03/05/02 TUE 15:11 FAX 1 9 _0430 SECOR-SACRAMENTO Z002 <br /> WELL PERMIT APPLICATION FORM Mj GATION <br /> SAN JOAOUIN COUNTY PUSLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION CPA ) <br /> 95202 <br /> Weber,Third FIDor, Stockton, <br /> 304 E. (209) 468-3449 <br /> IT EX IBES t Yfi R F OM D TE I SUE <br /> ON-REFUNDABL PER 7hisa 3lcEn iron nlll Ha th 101vsi nlance L- <br /> fora permll la construct ondlor Install the ymrk described• Apaessors <br /> 1,San ,24_f19/J—Q� <br /> APPIIca°0n is hereby made nt TItie,ICriapn Covnry _CM <br /> ter "n 5.3 and lna Standards ofpS�a�n�Jyoar4u5ln.}Counry Public Healtt+ e <br /> Joaqum County DevolaDYfeSum -Cily <br /> CA <br /> 2 ( r PgPnonA#terr"^ <br /> WELL Location n C -U <br /> fill n.nlr �t(. .Id VP' ddiP LIr Phonek �i� <br /> PROPERTY OI+I er jj�� re <br /> 1 - •;C C' PhoneN .UIP •��oO <br /> t�Q,SJ(' AddFess <br /> t Lit <br /> Address <br /> C-57 Contract r Gky A A qstP� <br /> lG(t no SecdOn�— <br /> Consultant/Sub Gontractor.,�-.'.`'�`� Townanfp�Rangel—' <br /> GLS Coordlnales17 1� p DES7RUCTION 10110051 type below) <br /> tl DYER-BORE <br /> W RK YO BE E FORMED_ (J PRESSURE GROUT <br /> L-0ther: <br /> RORING l cPT,GEOPROEE,MYOROPUNCH.HPND-AUGER.OTHER' <br /> SOIL BOR G>! Grout Speellirallons= <br /> YIW ELL# <br /> p <br /> WELL CARING DI <br /> C mS UCn NSP CIFlC SI MULTIPLE CASINGS?DYES)(I <br /> TMop— O IN TALL TION E <br /> HOLLOW STEM DIA.OF BOR0F10LE���1�1�j—D Ty.PE OF CASING: 057EEL PVG DOTHER• <br /> V�MONITORING CASING THIGKNESS�:LLi TRE AIE T(PE TO BE USED: ) AUGERS t]HOSE <br /> EXTRACTION U AIR HAMMERIDRIVEN <br /> MUD ROTARY DEPTH OF GROUT SEAL IOC <br /> p VAPOR GRO'�SEAL PUMPED: p Yea 0 No (NOTE:MAXIMUM FREE-FA4L DEPTH IS 3 <br /> 01 <br /> SC a AIR SPARGE Q PUSH POINT STOVE PIPE <br /> n HAND AUGER PROUY SPECIFICATIONS: OLTED TRAFFIC BOX or <br /> OJGY Q 301E BORING APPROX•BORING DEPTh 1f YES list specif,=tlons hats):�1— <br /> QoVER: OTHER_--- CONDUCTOR CASING PROPOSED. t <br /> -COMMENTS: R ENCROACHMENT PEi3MITS_ <br /> NOTE: OFFSITE BORINGS REClU1RE ACCESS O <br /> CAtL THE UNIT()FF <br /> INSPECTOR 48 W RKING HOURS IN ADVANCE FOR ALL REQDIRED INSPECTIONS, <br /> p IICCation and that the work Will be done in accordance with San Joaquin <br /> cerlffy that 1 have prepared this a p' h G <br /> s,Rules and Regulations,and all aPPII�b16 California State s• <br /> I hereby <br /> County O in ri TidelCompan) <br /> Dal 1 f� <br /> Signed <br /> S S DEP TMENT USE ONLY <br /> O�-7 <br /> I PdrtNama <br /> SITE MAP IN UNIT IV FILE, ADDRESS: L <br /> WORK PLAN DATED' Date Issued pa <br /> F1nal Inspection& <br /> Applird5on AccaplAd By ' <br /> fate <br /> Grout lnsPeOgon By Date <br /> Destrucdan InsP�rrbrl BY <br /> COMMENTS i CONDITIONS! cera INVOICE <br /> ACCOUNTING ONLY: AID# RECD BY DATE PERMIT 155RVICE REQUESTO <br /> PE CODES FEE INFO AMOUNS REMPITED CHECK# �IS <br /> O a` 9/27/00 <br /> 3 I ,© C7 nlit�Encroachment docs <br /> G$7� WC!WAIVER+ <br /> C-57 LQttex of Authorization to slgn per' <br /> I <br /> I C64E39060i; <br /> LP:4T Z00Z/50/C0 <br />