Laserfiche WebLink
09/08/2004 11 :05 FAX 9186792900 URS-SACRAMENTO-GO Z 002/004 <br /> CI.1:''20/20C14 1Id: 24 20946*3 FIFTH FLOOR • PACZ 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EF#D) <br /> 304 E.Weber, Third Floor, Stockton, GA_, 95202 <br /> (209)468-3449 <br /> NON REFl1_FL04BLE PERMff PIRE$ Y K p TE $ eD <br /> Applimn Geunhebow ada t tSan Chap„ county r3 and rmit o woad t Se�a mll l unty invironmental Heat)Dapartrn nl%A In compliance with Sen <br /> iLsesmr s <br /> Joaqul h' :&C:_f U SS �'-� c.(t Zip 5.52 N I Panel# <br /> WELL Location z�s s-�(�`�tik'2� Crops Sfr'eet l Giiy <br /> Ll 1- � ->� �� �-e City, 4(1 6P. Ck ono�r <br /> PROPLRTYOwnr_rL4 Address_ �_ � 7t <br /> �`1�City�jJp�Icil�PCIon.FF�, 1 :G - <br /> G-57 Conlracln'Vl/W_e(' �t11(�1��re6s� - 3�tL 'l1 4�,!o�i-I—'2, <br /> ,� � t{Wq_ �Sac-cu►.+�,Td7c,'F�Pnan�� <br /> GonYulunt I Sub Contrac:tar_ U <br /> �y{tai7� Atldress ^� <br /> J Y .7ownsilip <br /> Eian�a Sce6an <br /> GIS Crtorcllnat®s'X,�T._� <br /> WOC2K 70 BE PFRFORMEO: p OF_S'fRUC-rION(choose type below) <br /> p NFWELL I BORING(CPT,GEDPR06�.HYOROPUNGH_NAND AUGER O fHER�) p OvSR-BARE <br /> OIL BARING iF PRESSURE GROG <br /> D W ELL# Groul Specifications: <br /> "Other, W b\1 d Die 0- wC i� 2t S <br /> COMMENTS: 01l <br /> � TYPE C]t WELL N�TnL OIJ TypE i1CTiON$PFt:F 4N8 <br /> l YES 0 NO VVELL CASING DIA <br /> j MONITORING f}HOLLOW STEhI DIA,C1E 80REHpt1r MULTIPLE CASINOS. Q <br /> AIR HAMMERjuRIVEN CASING THICKNESS_��TYPE OF CASING: p sT�EL q PvC p <br /> 'rREMIETYPI=70 8E L1SE=1�: 0 p.UGERSERS 0 HO' <br /> Q VAPOR 0 MUD ROTARY pEPTH OF GROUT SEAL, <br /> GROUT SF-FL PU&Ip6P: 0Yes 11No (NOTE: MAXIMUM FREE-YA•LL DEPTH 1S 3' <br /> p A,IR SPARGE ❑FUSH POINT GROUT SPECIFICATIONS' <br /> (]SOIL BORING NAND AUGER 0I3OLTeDyWFICB0X or IlSTOVE.P1PE <br /> dOTHER:T__ �p <br /> O7HER� APPROX.BORING DEPTH <br /> CONDUCTOR CASING PRPON if YE�t SpeciTC24on:c here),'— <br /> E <br /> `COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS <br /> ADVOADAC EOUIRmp INSPECTIONS. <br /> CALL THE UNIT IV INSPECTOR 4B WORKING HO <br /> I hereby certify that I have prepared this application and that the work Will be done in accordanCe WAth San Joaquin <br /> and ulati S,a all applicable Callfvrnin Skate Laws_ <br /> County Ord C y� <br /> Tlnrlcempeny. tC1 e CA <br /> 5i9ncd - �a1e <br /> prim Name ~ 1k� ,, DEPARTMENT/" USE ONLY <br /> .911E MAP IN UNIT IV FILE,ADQRE <br /> WORK FLAN DATED; I 3 0 <br /> 1.l V� 0zle Issued 1 4( wga <br /> Appl[ca+ion Accepted coypate_ Flnal Inspection By <br /> r;;Mur Inspection By_ 1 4 b� r <br /> pcsllUcllon 1115pec6ori 9y ' v Lt r l <br /> ��. <br /> COMMENTS 1 CONOFFION5: - <br /> ACCOUNTING ONt.Y; AID# <br /> PE CODES FEE INFO pHIOUNTREMR7ED CHECK# REC,0BY [ATE P�RNIrrlsgRv'cEREnUEST tNVOIc' <br /> - - <br /> lig <br /> rllerlt dot <br /> G 57 WC,�WAlVER_ <br /> C-57 Leiter of AnthoriZatian to sign permit Encroach <br />