Laserfiche WebLink
6 0 <br /> tau.'n. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> �• <br /> Telephone:( ) &3454 Fase-3433 Wb <br /> Fax:(209) e :www siaov.oraed MITIGATION <br /> Tlh20946 <br /> rhUNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applca eon N hweby mala to San Joaquin County far s pentyl to o0nebuct enNar kroW dw work described TNa application Is made w,mrtpllance with San <br /> Joaquin Carty Dehabpmwd TB.,tlwPW 31115.3 arM the Standards of San Iuo n Courcy EnNrarerw"Heath Deportment. <br /> sw ry c � U �W.B Laton;OosXxcr' a aa AP14- <br /> Property <br /> wOff CeTO. Address L`O/ Y( Clry ijid .,d ZIp;Z9Z17 Ph.# <br /> Cs7colaacm. —S( r-:S Addr.n =0 N. EaK-d -S w6 city JOQZJ•..• np95Ti6 Lie# ROz3Sk <br /> a'IY , SitEee,(�,3Z! PaA.r � Ra' oD IH: <br /> CpraRaraMh4 Cntr ia'v r• ...�a.iui CMy S�c....asde Lk! Ptgm�glt, y1�8354 <br /> GIS CoordlnsM:x ,Y ,Township Range Section <br /> o�C To�E ae�oaLED <br /> -SQ LL/ LO ICiT.. �}gaSSi v't3{( Oyu.) b0; DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BOR1NOt'RiM�i7►'SSiAdw� 5Y$ .fL. 'tn OpRVEEgRg-8U0RE DDIAMETERDWELL/ —Y ,� gPRESSURE GROUT <br /> ❑•OTHER ( �6RouT sPEaFICAnoNs <br /> ❑EXPLOSNES DETONAT hi CARD <br /> COMMENTS: <br /> ee— <br /> TYPE OF WELL INETALLATMIN TYPE CONSTRUCTION SEjQjr,&n= <br /> ❑MONITORING ❑HOLLOW slim DIA OF BOREHOLE _ ❑MULTIPLE CASINGS O MLILTP EVEL WELL CASING DW:_ <br /> ❑EXTRACTION ❑AR HAMMER,ORNyN CASING THICKNESS A�A TYPE OF CASING:❑STEEL ❑PJC ❑ OTHER MA– <br /> ❑VAPOR 13MMLO ROTARY DEPTH OF GROUT SEK 190' TREMIEFDTYPE TO BE USjqAUGERS[3HOSE <br /> C3AIR SPARGE/OZONE .8&USH POINT(GP OR CPD_GROUT SEAL PUMPED:❑YM 13 No MA)ONKJM FREE-FALL DEPTH 13 3M <br /> ASO*.BORING J❑HAND AUGER GROUT SPECIFICATIONS � �6, ' �A//Li 6-m. � <br /> ❑OTHER: y1 OTHER5o...rG APPROX.BORING Dim+J.��/❑I BOLTED TRAFFIC SOX OR [I STOVE PIPE <br /> COMMENTS: an arm," <br /> co.oucroR rwsPraroeFn—�Y�— <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKWG HOURS NOTICE REOUWfa FOR INSPECTIONS <br /> I hereby cerafy that I have prepared tats apI N 11 n and tet the work WIN be dwIa i accordance with San Joalll In county OrdIMRe.a,RuNa and <br /> Rep Awdon.,and a!applle"C&Vwnis Laws. <br /> Soled c.•r.Il2]r < 'fitldComveny Sewn✓ it fy� MW <br /> Print Name w'y P. M;Klfcicl� - Date Ozr /7 10 <br /> DEPARTMENT USE ONLY ,,� // <br /> SITE MAP IN UNIT N FILE,ADDRESS: ISO A/. S.A-�,P,th. Q.u-� StOL✓7d+ PR SDs <br /> WORK PLAN DATED: /) <br /> APPLICATION ACCEPTED B//YII /I�� ,, DATE ISSUED � �� AREA4_ <br /> GROUT INSPECTION BY I J l�C'x FINK INSPECTION BY I4,LM�-C�l' DATE <br /> DESTRUCTION INSPECTION axDATE <br /> COMMENTS1ICONORK)N3: GAO r /K.Q ^"Alf U+.-/Ll-_. 1 <br /> ACCOUN71NG ONLY! AID N FAC N <br /> PE CODE3 FEE INFO AMT REMRTED CI w-P CC. REmD BY DATE PERMR/SERVICE! INVOICE <br /> 71.01 85 - 005- q,61cl C /6 a SRf40S & <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2401 10/28V9 W ELL PERMIT APP <br />