Laserfiche WebLink
Mar-19-02 01 : 56P VIR -X, INC. 51( 368 7679 P.02 <br /> 03/19/1-002 1,3: 34 2994bli9q433 FIFTH FLOOR '%-w PAGE 02 <br /> 0.31u1jr4-�4 ririn rL-L�'4 <br /> WELL PERMIT APPLICATION FORM SITE <br /> pv <br /> SAN .loaau)N COUNTY MITIGATION <br /> IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 3"E.Weber,Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> Nom.00!UNRABLE ERRMrr E7[PIiiE t_YEJ E�M.DATEJSSIlE>1 <br /> PplicAdon is hereby mads to San Joaquin County far a permit to=rvsftd andlor kTstaff the wok described. This appllmbW is made In compliance with San <br /> 7aquin County De-k+pmontTits,Chapter 9-11 15.S=hd the Standards of San.leaquin County Em+Ironmerhal H"IM Deptartrnent <br /> 1- OG1/1 ci, 33p Parce#ii�'l`I �+5t Q <br /> TILLLocation S a'' W• 7 OSC4wL�Z. Crone 5treeE pity <br /> 102J q o.w- it7rn urs CV. <br /> ROPERT"rOwner �-tle� �r,G, Add i +� c City �np9'•?ZO_phone1Ea04I <br /> >ST Conirzclor U l(� AddrE33L I a Fi=lawr.o A, P t45T!V 76 5927 Pnartrxr �t U�s &-�67>a <br /> :onsukentfsub Contmcwr 17 ..^F2P Address^`i DOS„ler �l�ic�ko w�pryt`tanccao Lic#13 t72 phona#'�2� 2�`: �oG15 <br /> >IS Coordlnale3:X .Y <br /> 7ownshl0 Rahg� Seettorl <br /> y0p W TO IRE PERFORMEn- <br /> ]NI:W WELL/BORING(CPT. OPRDBE,HYDROPUNCH.HANP-ALIGER,OTHER-) �DESTRUCTION(ehoese type belbw) <br /> )OIL BORING t3 5i3 L _ a OVER BORE <br /> p WELL 1f 0 PRESSURE GROUT <br /> :OMMENTS: <br /> Zr F Ll I"§NALLAT*N_TYPE cOrss7mycrlom SPECIFICAttot�J5 <br /> ]MONFfaRING 11 HOLLOW s7EM DIA-DF IDOREHOLE MULTIPLE CASINW?0 YES 0 NO WELL CASING OIA: <br /> EXTRACTION 11 AIR HAINMEPJORfVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC, p OTHER; <br /> )VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_ _ TREM IE TYPE TC BE USED: '()AUGERS U HOSE <br /> ]TIR zPARGE B PUSH POINT GROUT SMPUMPED; QYea 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> OIL 8C"G U HAND AUGER GROUT SPECIFICATIONS; <br /> ] <br /> OTHER- OTHER APPROX.BORING DEPTA 0 BOLTED TRAFFIC BOX. or 0 STOVE PIPE <br /> r-ONDUCTIQR CASING PROP 6Q_� (RVIES•Gsc spedfiimbons here)•' <br /> COMMENT-9• <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 49 YUORKIKG HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby Cet'tify that 1 have prepared this application and that the work will be stone in accordance with San Joaquin <br /> county Ordinane Rides and Regulations,,and all applicable CellfOmi;a State Laws. <br /> 519 mod x NA Tilla(Corrcany <br /> 'Tint <br /> DEPARTMENT USE ONLY <br /> 31TE MAP IN UNIT IV FILE,ADDRESS: <br /> HORK PLAN DATED.• <br /> Vpti:awn Accepted By <br /> ;routInspectIonSy �. Oat;• �_ SOT__ FFln0Inepecton By <br /> r <br /> )estryWan Lispee0on Dy Dot. <br /> :DMMEKTz GOMDITIOMS: YlIVI <br /> ACCOUNT1NGONLY: AjD# <br /> ear* <br /> PE CODES FIE INFO AMOUNT RFMITTED CHEr-K to RECD BY DATE peRMTT I SERVICE REQUEST r 1NVOICE <br /> G-57_ INC_=WArVER C-57 Leifer of Autkorizatien to sign permit_Encroachment dor-_ 1/25/02 <br /> 03/05/02 .TUE 09:39 [TX/RX NO 54041 11003 <br />