Laserfiche WebLink
RE <br />FE �LI� !f��; WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY MITIGATION <br />AUG 2 9 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br />ENVIRA'v]EP: T HEALTH (209) 468-3449 <br />PERMIT/SERVICES MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a perm d/or install the work described. This <br />application Is Joaquin County Development Title, Chapter 9-1115 the Standards of San Joh County Environmental Health Departmentade in compliance with San <br />_ I <br />5FAi SrJSP— <br />WELL Location Cross Street city SToGKTD,v/ Zip Q�.20S Parsers <br />PROPERTY;,, MR. F69ESr W14ITF <br />Owner S,01 J0440VI /J Ti AddresAIRyOR.% C S%OCKTONZIpp5! Phone# <br />S;riw r C. <br />C-57 Contractor 6AZGG ZR+Lt'f(S+-Address %SD f/cw6 /Z�. CityH/��r, Zip9�SS3Ll 6/ia�Phone# 915-313-.�Bod <br />S's r �+ < <br />Consultant/SubCntrWRIGNT GNthF-6;yfiNqc�mss G7 E. /Off, S1 City ��}Cy Uc#6j-1so� P 833-0758 <br />GIS Coordinates: X Y T h' <br />oI +P Range Section <br />WORK TO BE PERFORMED,• <br />i(NEW WELL/ BORING (CPT, GEOPROSE, HYDROPUNCH, HAND -AUGER, OTHER-') <br />SOIL BORING # C P 7 - 3 <br />0 WELL # <br />0 'Other <br />:�OMMENTS: <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />rYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />I E-XTRACTICN 0 AIR HAMMER/DRIVEN CASING THICKNESS ~ I* TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />J VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL / / `7 TREMIE TYPE TO BE USED: <br />DAUGERS HOSE <br />I AIR SPARGE/ OZONE PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />1 SOIL BORING 0 HAND AUGER GROUT S <br />PECIFICATIONS \ <br />OTHER: n OTHER APPROX. BORING DEPTH //9 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list spedfications in comment section) \, <br />OMMENTS: A <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. t` <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />:ounty Ordinances, Rules and Regulations, and all applicable California State Laws. <br />gned x Title/Company12Zo1I EC -T f1A10fi a/Z <br />- WIZLGI4 T 5NVI9o�11-" 4tc <br />�ntName NS Date 742-3 3 <br />DEPARTMENT USE ONLY n• 0 : sTltl K -E s — <br />ITE MAP IN UNIT IV FILE, ADDRESS: SEE ATT /91C/_119 D F/6 A f <br />/ORK PLAN DATED: cTL' --J E ,26 o.yD. <br />Ti o �vs ,amu Ly I % '03 <br />plication Accepted By ✓ Vv Date Issued Qip 10/ ?003 Area <br />out Inspection By Date inal Inspection By Date <br />�struction Inscection By Date <br />7MMENTS / CONDITIONS: A (^( 25S oee y A <br />CCCUNTING ONLY: I AID# I FAC# <br />^DEc `7 'NFO IMQUNT Rc_MI TT=D :YEC:< = RE= BY DATE <br />?9 -op i U <br />PERMIT 1 SERVICE .REQUEST # INVOICE <br />i_ WC= WAIVER C-,7 Litter or Autho zat -gig perm;I Encroechmel�c9/30/02 <br />5 X533` <br />7 oT <br />