Laserfiche WebLink
B5/04/2004 14'17 2094683433 FIFTH FLOOR t PAGE 03 <br /> VII�L L PSR �T APPoLr <br /> AL <br /> RMSITESAN JOAQUIN COUNTY MITIGATION <br /> �QO ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT I1! <br /> (209} 468-3449 <br /> tyVICµ�OS? NON RCFUNDABLE PERMIT EXPIRE YEAR FROM[]ATE ISSUED <br /> Appfte��t__�rphs�h8ret7y rnddc to San Joaquin County for a permit to construct and/or ins,, the work described Tni�applraa#Ion is rts�da incompliance w th$fin <br /> Joaqulrf;aunty Develcpmeni Tittle' Chapter 4-i 13 3 and the Standards of San Joaquin County Environmental Health Department <br /> WELL Location IaO J. t�Ct4rr 44 Cross sacret Assessors <br /> C/ S City �� 1Jb�_zrp S33e Parcel'} <br /> PROPERT 1-4 pny&6c fo �jf� t� f� <br /> owner `Adore till -i ✓C�r CItY 1C Z,0'7 7 hon P# <br /> C 57 ContrOctor�„��e? <br /> Consultant/Sub Cntr�r"`b.�-t�Cj �1(! ��,gCtlrer.,s�r Z��'lLe' _�..� c� <br /> Phone��OZ 6%`6041 <br /> GIS Coordinates X YTownship -t� Range Section z 7 <br /> WORK TO SE PERFORME4 <br /> NEW WELL/BOR(NG (CPT G PROBE HYDiROPUNI'H HAND_AUGER OTHER-) 0 D1=STRIJCTION (choose ;ps below) <br /> OILBORING+ '�r _r_ <br /> [I WELL [)OV!"R-BbRE DIAMETER <br /> t � <br /> [I'Other 0 PRESSURE GROUT <br /> COMMENTS GROUT SPECIFICATIONS <br /> TYREa��WELL INSTALLATION TYPE COKISTKLICTION SPECIFSCATIONS <br /> 0 MONITORING [I HOLLOW$TEM DIA OF BOREHOLE�t_ GI MULTIPLE CASINGS Q MULTI LEVEL WELL CASING DIA <br /> • 9 EXTRACTION 11 AIR HAMMER/DRIVEN CASING THICKNESS TYPE bF CASING D STEEL D PVC I1 OTHER _ <br /> [I VAPOR 0 MUD 01]E <br /> ROTARY PTH OF GROUT SEAL TRcMIE TYPE TO BE USED a AUGERS 9 HOSE <br /> >'RG <br /> p AIR SRAEI OZONE `j�[PUSH POINT(GP orCPT)GROUT SEAL PUMPED 13 Yes a No (NOTE- MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL E013ING, 0 HAND AUGER <br /> GtSOUT SPECIFICATIONS <br /> U OTHER Q OT61ER APPROX BARING DEPTH _ $ 0 BOLTED TRAFFIC BOX or [I STOVE PIPE <br /> Cd{vEMEf+IFS <br /> CONOUCTOR CASING PROPOSED (If YES list apecifimtions in comment Spction) <br /> _ <br /> NOTE OFFSITE BORINGS PE-QUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS � <br /> 48 WORKING HOURS NOTICi= REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work Will be drone In accordance with San Joaquin <br /> County Ordr antes, Rues matrons, artd all applicable California State Laws <br /> Signed x <br /> Ti,lelCcrrspany � � f �✓1 U�� krr.t�.c <br /> Pnnt Name f� LQ�'L �(' �-� ,L Cf e. <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS ' (� <br /> WORK PLAN DATED IX1,3f t C} <br /> APPlicatiun Accepted By_ " _ _pate Issued -Ares <br /> Grout Inspect=By. Date_ ` Final Inspecbon By <br /> Destruction hspeeion By Date S e <br /> COMMeNTS I CONDITIONS <br /> ACGOUMTING ONLY AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED ChECK* RECM By DATE PERMIT/SERVICE REQUEST# INVOICr: <br /> 3661 sS a-� ��� O L( SR# 3 _71i7 j <br /> G-57 WC -WAIVER_ C-57 Letter of Author izat1Ion to stgr pertnrt____Fncroack rnent dot <br /> 9/3Q1Q2 <br />