Laserfiche WebLink
i <br /> IW29/21MI3 14:56 2094'~1.,433 FIFTH FLOOR PAGE 05 <br /> WELL PERMIT APPLIC TION FORM SITE . <br /> SAN JOAQUIN CO NTY <br /> ENVIRONMENTAL HEALTH dE ARTMENT (EHD) MITIGATION <br /> 304 E. Weber, Third Floor, Sto kton, CA., 95202 UNIT IV <br /> (209) 468-3449 <br /> NQ -REF Dlat. RMIT XPi 51 Ft F OM ATE SSU D <br /> Application is hereby made to San Joaquin County for a permit to construct andler install t1 wont described- This appii # <br /> Joaquin County pevelopmant Tido.Chapter 8-1115.5 and the Standards of San Joaquin ca on is made in compliance with San <br /> un vlronmontal Health Department, <br /> WELL Location y`E5� Cross Street � Assessors�y <br /> City Zip 9arcel# v — <br /> Pf:OPERTYOwner G9S� � Address3or�,, ' rr. s <br /> CifJr .a!If ZrpZl.�_Phone#._. 'Y'� ��I. , o <br /> G-57 GanlraCtor e✓ eCE Address CI - <br /> 9�-Phone <br /> Consultant/Sub Cntr � r i(/ Address'tel �f` y <br /> GIs Coordinates:X Y , <br /> WOTawnshl <br /> p Range Secuorn <br /> E P FO <br /> EW, WE L 1 BORING (CPT t:OPROB .HYDROPUNCH,HAND-AUGER,O ER') q DESTRUCTION choose <br /> Dll,BORING# ( type below) <br /> ELL# 3 OVr;R-BORE. DIAMETER <br /> U"Other ij PRESSURE GROUT —� <br /> COMMENTS: GROUT SPECIFICATIONS <br /> Z9 OF LL INS LATION PE PNS UC rl Sp CI ICQ 3 <br /> tvIONITORING IOLLOW STEM DIA,OF SOR✓=HOLE <br /> D EXTRACTION AIR NAMME � 0 MULTIPLE CASINGS U MULTI-LEVEL WELL,CASING DIA; <br /> R/DRIVEN CASING THICKNESS •OA ��� <br /> U VAPOR 4 TYPE OF CASING ]]STEEL C°L Q o-rHER_ <br /> []NiUI]ROTARY DEPTH OF GROUT SEAL%e. <br /> �"TREMIE TYPE TO BE USE!]: GERS <br /> 41R SPARGE/OZONE RUSH POINT(GP or CPT)GROUT SEAL PUMPED:. o OTE: MAXIMUM FRi=E-FA EPTHpS 3Q') <br /> SOIL BORING Ij HAND AUGER GROUT SPECIFICATION - <br /> p OTHER: OTMAPPROK BORING DEPTsJ. LTED TRAFFIC BOX or �STOVE PIPECONDUCTOR CASING P �__(i{ YES,list specifiCations In comment section) <br /> COMMENTS; <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRE FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances,RUI s"bnd Regulations, and all applicable Calffo nia State Laws. <br /> Signed x - � <br /> " TidelCompany, <br /> Print Name , /+ <br /> DEPARTMENT USE NLY [3dte <br /> SITE MAP IN U IT IV FILE,ADDRESS, <br /> NORK PLAN DATED: Z�5*4 <br /> plication Accepted By date Issued <br /> rout inspection Area <br /> E3y <br /> —Date Final Inspection By <br /> ?estivcdon Inspection By Data Date <br /> '01dMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: ALD* <br /> FAC# <br /> PI=CODES FEE INFO AMfMITTED' CHECK# REC'D BY DAPERMIT J SERVICE FiEQtIEST# INVOIC!<3: 7t 71, f� ag SR# 00 3,�'S 3 <br /> W(-WATVER.�, G-57!_etter of Avthorizatiox�to sin errnit <br /> 9 p Encroachment dac 9f30/02 <br />