|
a DESTRUCTION (choose type below)
<br />fl OVER-BORE DIAMETER
<br />a PRESSURE GROUT
<br />GROUT SPECIFICATIONS
<br />\1\
<br />P-A5 -t-c17 6 fl —
<br />1@/@8/2@@2 1@:47 2094683433 FIFTH FLOOR PAGE 04
<br />[plEcErm MLL PERMIT APPLICATION FORM
<br />ll l_vir M SAN JOAQUIN COUNTY
<br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD)
<br />JAN 2 4 20304 E. Weber, Third Floor, Stockton, CA., 95202
<br />ENVIRONMENT HEALTH
<br />(209) 468-3449
<br />DERMIT/SERVICES' NON-REFUNDABLE PERMrT EXPIRES 1 YEAR FROM DATE ISSUED
<br />Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in compliance with San
<br />Joaquin County Development Title, Chapter 9-11'15,3 and the Standards of San Joaquin County Environmental Health Department.
<br />(IP AA A 5 k F -ti e-WNy P.:(j.-t04, i--- ,, Assessors,
<br />WELL Location fa Hz) --/3:/.0 3 , .;.-‘,(6,,,,,..-1-: St Cross Street City i fp s' /. : Zip 75-R (1-1/ Parcel# i'l' /4
<br />Address tk)490 1--cif m:,i..-- '..' r. City d' 0 ;vi Ail x )1s4 5'ip C210 2-, Phone#
<br />C-57 Contractor 1,--V't,5 0, 114,.,,) Address 7 5-6) k7'4_ r\ I i City MA( i-,,,12, Zip c7 Y,5s,SiLic# C.C-0/ 7 Phone# ( 923-40Pje - 5-SO 61
<br />Consultant / Sub Cntr 'FA L- Address 5-6,k te.,,,,,Pre.,,, I (-Je city <,-, t,..a ucts Phone# (/23 ) epf -/ 2 00
<br />SITE
<br />MITIGATION
<br />UNIT IV
<br />PROPERTY Owner 14.1; Pfnt, c /9116 I
<br />
<br />GIS Coordinates: X , Y , Township
<br />WORK TO BE PERFORMED:
<br />NEW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER')
<br />1 SOIL BORING # - /
<br />
<br />IIIWELL# -A - 'A --<'?
<br />
<br />-.Other
<br />COMMENTS:
<br />Range Section
<br />INSTALLATION TYPE
<br />I HOLLOW STEM
<br />U AIR HAMMER/DRIVEN CASING THICKNESS Sci, tf-0 TYPE OF CASING: a STEEL § PVC rl OTHER:
<br />O MUD ROTARY
<br />DEPTH OF GROUT SEAL 4> —50 ,ts TREMIE TYPE TO BE USED: I AUGERS a HOSE
<br />PUSH POINT (GP or CPT) GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30')
<br />HAND AUGER GROUT SPECIFICATIONS ke,,t ti-
<br />O OTHER APPROX. BORING DEPTH 7o F, § BOLTED TRAFFIC BOX or U STOVE PIPE
<br />CONDUCTOR CASING PROPOSED N (if YES, list specifications in comment section) '1-
<br />COMMENTS: eq31-112- el 4- r, r S i 10 k nt
<br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS.
<br />48 WORKING HOURS NOTICE REQUIRED FOR 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 • e • . nces, Rules and ti s, and all applicable California State Laws.
<br />Pt/(J AP ( litle/Company
<br />l(7-3 ( 0
<br />SITE MAP IN UNIT IV FILE, ADDR)eSS:
<br />WORK PLAN DATED: Ctif, (--*"
<br />6iPOlicetion Accepted By, /--t.A._&-e----( Date Issued /./.1"- 7ie)3
<br />Brout Inspection By 440-4----cr"."1" Date I (2-41a Final Inspection By Date
<br />Destruction Inspection By Date
<br />Area (thie C i7/0 4/
<br />
<br />:-.0MMENTS / CONDMONS 1 A • u--19 P t • (51A
<br />ACCOUNTING ONLY: AID#
<br />L
<br />FAC#
<br />PE CODES CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERM ICE REQUEST-#) INVOICE
<br />Ake_ //2).7 0 SR# oz c3f---
<br />TYPE OF WELL
<br />§ MONITORING
<br />1:1 EXTRACTION
<br />O VAPOR
<br />Li AIR SPARGE/ OZONE
<br />fl SOIL BORING
<br />U OTHER:
<br />CONSTRUCTION SPECIFICATIONS „
<br />DIA. OF BOREHOLE ' a MULTIPLE CASINGS I] MULTI-LEVEL WELL CASING DIA:
<br />DEPARTMENT USE ONLY
<br />Date
<br />C-57 WC -WAIVER
<br />
<br />C-57 Letter of Authorization to sign permit Encroachment doc
<br />
<br />9/30/02
<br />
|