Laserfiche WebLink
OCT 2 5 2004 <br /> M61j- lo WELL PERMIT APPLICATION.FORM F%t= <br /> QGf h `7{D r� 11 �' 'i•iI0ES MITIGATION <br /> A^ SAN 'JOAQUIN-COUNTY UNIT IV <br /> Q ( �SI M ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 2265 6.FvewewfSt. 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> ----- - NON REFUNDABLE-PERMIT EXPIRES 1-YEAR FROM DATE ISSUED- ------- .. _ <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 /> .,�f ����,y Assessor's <br /> WELL Location �iOC7 G• ei�Addre,� <br /> IM O'IuT7�: Cross Street�City zip Parcel#PROPERTY Owner Address 21f�5 Fc -Ay w-ftf Sf' City .ZiP Phone#,(2a��fbf-5C-57 Cntram r . LLC-� t �� 0a MN�T`I�Ci Zi ����""L��i����yy Phone# <br /> Consultant/Sub CtffFlfwwWtrONwo4Q Addre. (� e�trO { .I ityE+( Lic#�L-Phone# �r-U40 <br /> li 'n " Section <br /> GIS Coordinates:X ,Y I� ,Township - Range <br /> WORK TO BE PERFORMED: . - it T DESTRUCTION(choose type below) <br /> UKEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) II OVERBORE <br /> l SOIL BORING# ( - - 0 PRESSURE.GROUT <br /> `WELL# 111 — le <br /> *Other. t Grout Specifications: <br /> COMMENTS , <br /> I TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS • - ^fr <br /> ,*ONITORING m JIOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?a MULTI-LEVEL?a WELL CASING DIAD d- <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS$lG IfU� ��TYPE OF CASING: p STEEL ) PVC p OTHER: <br /> U VAPOR a MUD ROTARY ,DEPTH OF GROUT SEAL � '�-t�—TREMIE TYPE TO BE USED.�UGERS a HOSE <br /> a AIR SPARGE/Ozone a PUSH POINT GROUT SEAL PUMPED: U Yes �,tlo (NOTE: MAXIMUM FREE- ALL DEPTH IS 30') <br /> p SOIL BORING a HAND AUGER GROUT SPECIFICATIONS:�� - ep�OLTED TRAFFIC BOX or p STOVE PIPE 1 <br /> Q OTHER:_0 OTHER h PPROX.BORING DEPTH `7�_ a` <br /> f - CONDUCTOR CASING PROPOSED? (it YES,list specifications here): <br /> *COMMENTS: - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 481WORKING 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 Ordinan les and Regulations, and all applicable Californi State Law . / u✓ <br /> Signed x '.V ' Title/Company <br /> .G. � 53 Date 1 <br /> Print Name <br /> DEPARTMENT USE ONLY ) <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> II y I <br /> WORK PLAN DATED: <br /> I <br /> Area �' <br /> y- <br /> Application Accepted <br /> BY d By i Date Issued <br /> Grout ins l€ Date "3.^ Final lnspecti <br /> p� <br /> Destruction Inspection By ,F II Date j <br /> I <br /> COMMENTS/CONDITIONS: II l a <br /> ACCOUNTING ONLY: AID# - - -- <br /> PE CODES FEE INFO AMOUNT REMITTED iCHECK it RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE i <br /> DD 9143 ! <br /> G-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encdoc <br /> 8/29/0 <br />