Laserfiche WebLink
• FILE COPY <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> lot *ii 600 East Main Street, Stockton,CA 952023029 MITIGATION <br /> Telephone:(209)4683449 Fax:(209)4683433 Web:www Siaov Ordehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> os rt�(pIRES 1 YEAR FROM GATE ISSUED 6 Dj r <br /> ltt San <br /> AppWcatlon is hereby made to San Joaquin County for a Pemnt to G011SHr A andlor install thedesaibed.al Heaah Doparunenm�in compliance wl <br /> Joaquin County Development Title.chapter 91115.3 and the Ston s of San Joaquin_ Assessofs <br /> Well Locadw�01Y91;j�ACross Street a� <br /> Sf( t Ir p �Gy <br /> Property i I T ', 4 ACdress '� l„+•�Pd city 11k'w&a kgwezlp'15371 Phone# <br /> o.n.r hO1e, 00 <br /> C-57 cerd.acmr �n% " Address 172641'ie 42h& �u,��A� city 1 la�al u�# <br /> l�rYtx,✓wrt✓ n%f C7�ty )ar1� — L:.It l� Ptoner/ ` -J/3 j <br /> � •�":�( _ ILI.57A Township RangeSecBon <br /> GIS Coer4llMles:X—/ 1.j <br /> WORK TO BE PERFORMED: ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ORlNG(CPT GEOPROBE,HYDROPUNCH,H DAUGER,OTHER) <br /> ❑OVER-BORE DIAMETER <br /> TY I9.dd' NEW�jSOIL80RNG# l <br /> El PRESSURE GROUT <br /> 0 WELL# GROUT SPECIFICATIONS <br /> ❑•OTHER <br /> COMMENTS: ~" <br /> w+¢ru 1 a710N TYPE <br /> CONSTRUCTION ATKMIS <br /> TYPE Of#YELL JJ 1 , <br /> ❑MONIITORING ❑HOLLOW STEM DN.OF BCREHOU."i! ❑MULTIPLE CASINGS�MULTI{EVEL WELL USING DIA:_ V <br /> � <br /> EXTRACTION [3 AIR MAMMERIDRNEN USING THICKNESS <br /> TYPE OF CASING:O STEEL ❑PVC ❑ OTHER <br /> D ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED[3 AUGERS❑HOSE (� <br /> ❑VAPOR ❑MU (\� <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:0 Yes ❑No (NOTE:MAMIAW FREE-FALL DEPTH IS 301 <br /> BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> vSoK- <br /> ' APPROX.BORING DEPTH -- O BOLTED TRAFFIC BOX OR [j STOVE RPE rn� <br /> ❑OTHER: �[OTHER- OONDMTORCASa1GPAOPDSED (y YEs.ksl spedreaNms b�mmxl o^7 <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> ,8 WORKING HOURS NOTICE REWIRED FOR INSPECTIONS �r <br /> I hereby urWy Mill 1 haw Prepared INS appllcallon and dud dw w"k well W 400101 sccoldarlcw 54e1 San JoaOldn Courtly Ordlnancaa.Rules and `l <br /> 'G V <br /> aa"I a Laws- . _ <br /> s ��' C�f�� TlaalcanPany � C/,// <br /> Print Name - l %/) Date / `' t <br /> E U LY-6Q <br /> SITE MAP IN UNIT IV FILE,ADDRESS: d 0 <br /> WORK PLAN DATED: AREA�a <br /> APPOCATKIN ACCEPTED BY B -p <br /> GROUT INSPECTION BY FINAL INSPECTION BY 1� DATE // <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE WFO AMT REMITTED CHECK# RECVD BY DATE pERMRISERVICE# INVOICE <br /> p0/!/v 2 S _ <br /> G57 WC -WAIVER C57 lF1TEf AUTHORIUTION TO SIGN PERMIT E m1/w.—{�— <br /> WELL/Pw/r(j Tw� <br /> D19ef <br /> O1 ILSOT(wFB) .,.r <br />