Laserfiche WebLink
NOU-30-2000 15 013 GEOMATRIX FRESNO <br />559 264 7431 P.03iO3 <br />EL.L. PERMIT AFPLICATION rORM SIVE <br />p <br />N JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIUMITIGATIONA3MITIGATIONV <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />NIT IV <br />304 E. Weber, Third FBeor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON.REI=UNDABLI=E:RMTT EXPIRg§ 7 YEAR FROM DAT9 l <br />Application is hereby made to San Joaquin County r"or a permit to ransiruct and/or install the worts descrlbed. 'This application is made In compliance with Sart <br />Joaquin County Development Title, Chapter 9-111-6.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division, <br />Assessors <br />WELL Location Cher V Road_ CrossStr®etE. Hwy 12 CityViCtOr, _CA np95253 Par>"I# n/a <br />PROPERTY Ownressl810 E. Eazelton Avelty Stockton zip 95205 Phone# 209-468--3057 <br />"7 <br />Cons <br />5"46$ iL <br />559-264-2535 <br />GIS Coordinates: x Y , Township 3North Range 7East Section__4_ <br />WORK TO IME IBRFORMED: <br />&NEW WELL I BORING (L -FT, GEOPROBE. HYDROPUNCH, HAND -AUGER, OTHER") o DESTRUcrON (choose type below) <br />13 SOIL BORING AtQ OVER -BORE <br /># Q PRESSURE GROUT <br />'Other *W ELLGravt Specifications, <br />COMMENTS:Well located 2x000' north of H -12 on west side o C erry R . ri.g t -o -way <br />TYRE Ole E <br />INST LAT110V <br />XWONITORING <br />IWOLLOW STEM <br />Q EXTRACTION <br />9 AIR HAMMEPWRIVEN <br />O VAPOR <br />Q MUD ROTARY <br />Il AIR SPARGE <br />p PUSH POINT <br />Q SOIL BORING <br />Q HAND AUGER <br />a OTHER: <br />D OTHER <br />CONSTRU_GTIRS SPEClF_ICATIONS <br />0}A. OF BOREHOLE 10" MUL-npLE CASINGS? 0YE5 W40 WELL CASING DIA: 4° <br />CASING THICKNESS Sl?h . 40 TYPE CF CASING: U STEEL }'SNC 0 OWER_ <br />DEPTH OF GROUT SIAL 52L bgs , TREMIE TYPE TO BE USED: &RUGERS Q HOSE <br />GROUT SEAL PUMPED: jUm 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301 <br />GROUT SPECIFICATIONS: Bentonite/cement sl=ry <br />APPROX. BORING DEPTH 50 t ]gBOLTED TRAFFIC BOX or n STOVE PIPE <br />CONDUCCOR CASING PROPOSED? No { if YES, list specifications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS 1N ApVANCE FOR ALL REQUIRED INS <br />I hereby certify that I have prepared this application and that the Work will be done in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed rpry <br />Print <br />_,faA <br />SITE MAP IN UNIT 1V FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By Dale Issued 12_1[14106 AM <br />Grout Inspection By Dare L Loo Final Inspection 6y _ �� -�� ._=Dat Z-71a— <br />Destruction Inspsctlan By Date <br />ACCOUNTING ONLY: I AID# <br />AE CODES I FEE INFO I AMOUNT REMITTED I CHECK u 1 RECD BY I DATE <br />2,9(cI <br />to(•00 1 pzs 13 -3� <br />C--57 WC-WA_ZVER C-57 Letter of Authorization to sign <br />ix 1 INVOICE <br />O O xq 19 3 <br />TOTAL P.03 <br />9/27/OC <br />