Laserfiche WebLink
i <br /> CATION FAM SITE <br /> RECENED <br /> WELL PERMIT APPLI <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> JAN 1 8 7005 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> Et&IRONMFNTHEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made <br /> ameto San nt Title IChapteC9-1115.3 and thefor a l-t to construct Standa ds of San/or Joaquin County Envll the worK f onmental Health cribed. This liDetion is partmen�de in compliance with San <br /> Joaquin County Development G� ,/ Assessors <br /> 0 it/ �i /�� Oil./M460 city fA.G Zipj5 <br /> Parcel# �N8 � o`�-���� <br /> WELL Location e5 Cross Street n �pp ty <br /> /nJ 1 l '�?0 )6e,4e5 / qu4 City � CG Zip 535(, Phone# a $;3S' ?:* <br /> PROPERTY Owner lJC��e �l rvs. eajj Address �3 <br /> j� fj� a<C�" Zi ! �Lic# �lJ•?L Phone# <br /> Nt Address ' 3(ds���4rfir� City P_L-- <br /> C-57 Contractor � 7iil�U' _ r1, �1 I, <br /> fr 1v,vfe(Wej- Address <br /> ��15 E/ �Yd7�'�- City 5-Lr Lic# Phone#3)02 4CS—'571J- <br /> Consultant/Sub Contractor <br /> GIS Coordinates:X ,Y <br /> Township .3 � Range � � Section <br /> WORK TO BE PERFORMED: �r/� DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) A fv L1 `--� M W21 ROVER-BORE <br /> 0 SOIL BORING# 1]PRESSURE GROUT <br /> ;WELL#_ ' r Itl".4Ced-tr -/d n /� <br /> Grout Specifications: <br /> Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS LTIPLE CASINGS?0 YES NO WELL CASING DIA: <br /> MONITORING ;1HOLLOW STEM DIA.OF BOREHOLE_ '(P <br /> a EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS ��STYPE OFCASING: <br /> EI TYPE0STEEL <br /> TO BE USED:V AnUOGERS []HOSE <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Yes p No (NOTE: MAXIMUM FREE-FALLDEPTH IS 30') <br /> GROUT SPECIFICATIONS: Ne•.f fit'"� 9y �`� wpb S ���/�1���" ���f���•�� �S/` <br /> Q SOIL BORING HAND AUGER 6 BOLTED TRAFFIC BOX or STOVE PIPE <br /> OTHER APPROX.BORING DEPTH � � <br /> 0 OTHER:___ ---- <br /> Nt`'� /CONDUCTOR CASING PROPOSED? IfG_(if YES,list specifications here): <br /> "COMMENTS: I `W q -10 6e 4&04116 6U���J 4- /`e i' M lLi tIr <br /> REQUIRE ACCESS <br /> NOTE: OFFSITE BORINGSN D ONCE FOR ALLENCROACHMENTREQUIRED <br /> UIRED INSSPECTIIONS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOUR <br /> I hereby certify that I have prepared this application <br /> and <br /> ttthe work <br /> ill'be done Laws.in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations) l <br /> / Title/Company S T GCc <br /> Signed x % ��'��e ( � <br /> Cy �� Date / <br /> Print Name �✓a1 nfr DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: a "— <br /> WORK PLAN DATED: <br /> 6S <br /> Date Issued d 0� Area -Y <br /> Application Accepted By ► ` L Date t Final Inspection By DaterM 14L <br /> Grout Inspection By <br /> • <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# cern <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE' PERMIT/SERVICE R <br /> ,Z1 a / 0� O' S y / ;-379 / sR# q1 a. DEQ T# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> 1/25/02 <br />