Laserfiche WebLink
WELL' ERMJT APPLICATION F� i� <br /> f� x SITE <br /> SAN JoAQUIN COUNTY MITIGATION <br /> DEC 12 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT Ill <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENT HEALZ"H (209) 468-3449 <br /> AERNIMSERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;l <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department- A <br /> WELL Location I i 1 G- G 6At v— & � Crass Street City Ef z;p e�l 1 P rel#Assessors <br /> PROPERTY Owner- mLl r —" <br /> a-. .� - G►[aa(L1�t�� jddress r� 5 Citynr�AL(il p Phone# 9 <br /> C-57 Contractor CO.12__D� Address �7 City Ztp Lis# - Phone# <br /> Consultant/Sub Cntr��� Addres .__�� /s :-f�1al� City-ic# 6 2-7Phone# — <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: a <br /> EW WELL!BORING(CPT,GEOPROSE,HYDROPUNCH;HANG-AUGER,OTHER*) DESTRUCTION(choose type below) <br /> 1 ©SOIL BORING# Q OVERBORE <br /> [j WELL# [j PRESSURE GROUT <br /> 'Other: Grout Specifications., f �. f <br /> COMMENTS <br /> i <br /> TYPE OF WELL INSTALLATION TYPE, CONSTRUCTION SPECIFICATIONS <br /> [j MONITORING XHOLLOW STEM DIA.OF BCREHOLE_fjj(L MULTIPLE CASINGS?IJ MULTI-LEVEL?a WELL CASING DIA: i <br /> [j EXTRACTION AIR HAMMER/DRIVEN CASING THICI(NESSO TYPE OF CASING: I#STEEL XVC <br /> OTHER: <br /> `VAPOR o MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: �KPUGERS 11 HOSE <br />'` AIR SPARGE/Ozone p PUSH POINT GROUT SEAL PUMPED: []Yes [j No (NOTE: MAXIMUM FREE-'FALL DEPTH IS 30') I <br /> [I SOIL BORING fl HAND AUGER GROUT SPECIFICATIONS: <br /> 1 <br /> OTHER: ❑OTHER APPROX.BORING DEPTH OLTED TRAFFIC BOX or a STOVE PIPE= :I <br /> CONDUCTOR CASING PROPOSED? :f YES,list specifications here): <br /> *COMMENT'S: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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, Rules and Re Mations, and all applicable California Stajtte, Laws. <br /> Signed x_ Title/Company �i <br /> Print Name Irli/LOI S i7ate 0 } <br /> DEPARTMENT'.USE ONLY �3 <br /> " l <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: Ak <br /> I � I <br /> Application Accepted 8y Date Issues! �� Area t <br /> Grout Inspection B Date Final Inspection By Date ! <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> i <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC-D Y DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ii <br /> 3sqn L m7lo I ze <br /> C-57 WCC WAIVER C-57 Letter of Author acro sign permit Encroachment doc 8/29/02 <br />