Laserfiche WebLink
Br 131/2032 00. 47 2094683433 FIFTH FLOOR PAGE 03 <br /> 6;'177'206? i7: 53 20946B3433 FIFTH FLOOR PSE 82 <br /> WELL. PERMIT APPLICATION FORM SITE <br /> - <br />� SAN JDAQUIN COUNTY MITIGATION <br /> ISI <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 458-34.49 <br /> CAI.REFrIlN Afte PERMI XPJRES 1 YEAR P OM PA TE 155U1wD <br /> Abptlznon Is hsroby made m San Joaquin County far a perrnit to construct andlor install the work described. This application Is made in complian=with San <br /> Joaquin county Deyelonrr,cnt Tit(e,Chapter 9-1119.3 and the Standards of sen Joaquin County ErtvirortrnenNI Health Dcpartrr,ent, <br /> Assessor's <br /> WRLLLacatlanlLel 1 Wey�- Crossstr Ae S'S ciLy�o�K�Or� Zip.���0� Par—gl f3rS—l�o— fS <br /> PROPERTY Owner A�larJ.t -WQc ,l Cg Address"t[�-�jaX �eS4Q _CIW zip 4 1 70 Phvne#_Lf�}�S1 <br /> C57Contraatar�C ExQ`o�Pa►7 �gddres5 �3��^ �^n4T' COst9yolnp9S74SLic�!?455�tophone#��1�Y3�ya0o <br /> aJs70 G4i-r�¢�j ftiSmCi[y cr4 IGS_ �„F`hane 4� L71'aD00 <br /> Consultant I Sub Gantractnr U 915 Address <br /> GIS C.Qordfnates:>; ,y_,Township Range__. S6•CGon <br /> VWOR_K TO 6E PERFORkIKM <br /> N <br /> NEW WELL I aORING f CPT,GEOPROBE,HYDROPUNCH.HALN 7-AUGF OTHER-) []DE$TRUCTION (choose type beJaW) <br /> p$OIL BORING# d OVER-BORE <br /> fl WELL Q PRESSURE GROUT <br /> 'Other-, Grout Spc�uflcatians: <br /> COMMENTS: <br /> TYPE OP WELLWELL INSTALLATION TYPI* CONSTRUC`I'IOVO SPt"CIFICATIONS <br /> II MONITORING(3) 1 HOLLOW 5TEM DIA.OF 00REHQL.EI-,- MULTIPLE CASING57 Q YES ONO VVELL CASING o1+1= a <br /> Q rXl'RACTION p a)R HAMMERIDRWEN CASING-THICKNESS Sal `/Q TYPE aix-rgStNG: ]3STEEL @ PVC POTHER: <br /> p R p MUD ROTARY DEPTH OF GROUTS EAL 3'-s TREMIE TYPE TO BE USED-L I AUG2RS Q HOSE <br /> i� PA RGE D FLUSH POINT GROUT SEAL PUMPED-, p Yes j No (NOTE- MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL 1308 E a HAND AUGER GROUT SPECIFICATIONS. Aj-�J� eerrcev� <br /> p OTHER: ra OTHER APPROX.BORING DEPTH ��r ji BOLTED TRAFFIC 1309 or D STOVE PIPE <br /> CONC)UCTOR CASING PROPOSED? {if YES,list speci7 cottons here), <br /> CDMlr,ENTS: P1CASG -PXt4r » uaerK to d -71Y),=L <br /> NOTE: OFFS]TE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS, <br /> CALL THE UNIT IV INSPECTOR 49 WORKING HOURS IN ADVANCE FOR AL1.-REQUIRED INSPECTIONS. <br /> i` <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with yah Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws. _ <br /> Tiil�rJcromparly I r• f',`� <br /> Print Num <br /> DEPARTMENT USE ONLY <br /> C <br /> SITE MAP IN UNIT 1V FILE,ADDRESS". L <br /> WORK PLAN DATED. V <br /> Applicnlicn Arwprted By l . r" Date Iissued ` ZOO? Alva —� <br /> Grout Insaot�ioh By Gate Final Inepetbon Sy bate <br /> Oostruation InSpP4;ban fay Data <br /> COJNMEMT51 GOIVDITIONS: � 1'kd <br /> ACCOUNTING ONLY: AID# Carlo <br /> DES FEE INPQ AMQUNT REMI-rr9D CHECK V; ii1=G'Q ply DATE PERMIT l SERVICE REQUFST IT It1Y'oICE <br /> 10 Zg 0Z sR 06 �, <br /> C-57 WC_-WAjVER C-51 Letter of Autha i tv sign permit Entroachmcnt doc_ Z/�5l02 <br /> I <br /> I <br />