Laserfiche WebLink
CX:1 <br />0 <br />I ri e e Date / 2. /II /2-003 1 le r Print Name <br />DEPARTMENT USE ONLY <br />gbup <br />2,3 1 02—. <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Date Issued <br />Final Inspections Date <br />Date <br /> Area 61 <br />Date //-23 -10 <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS I CONDITIONS: <br />ORIGINAL <br />WELL PERMIT APPLICATION FORM <br />HEAL D SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />03 DFC I 5 p m 4: 0804 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 />Joa quin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />WELL Locatiora iii&poirr tAkty - 6 VAS Cross Street sr city SrOcktii ii Zip 4:15R06 Parcel# <br />OwnerC4116. frriy Via; Guarg Address 9900 Goer-he Rol <br />PROPERTY <br />City cac /weir; Zip 95V26 Phone# 914 V511.3606 <br />City Oro vi lie zip/516 6Lic#77700erP Phone# 5305992.270 C-57 Contractor .8,1 Pevlo Address Po nox 6093 <br />SITE <br />MITIGATION <br />UNIT IV <br />051- Om <br />WORK TO BE PERFORMED: <br />KNEW WELL! BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) DESTRUCTION (choose type below) <br />fl WELL # <br />U *Other 3,1 <br />,, a PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />Address tlaelisori ihic city FahroaksLic# <br />SG.ire. 16V <br /> <br />, Township <br />Consultant! Sub Cntr Vev-Satt" (Mc. <br />GIS Coordinates: X , Y <br />Phone#976 2'637726 <br />Range Section <br />SOIL BORING # . a OVER-BORE. DIAMETER 13ioi ela 6 <br />COMMENTS: <br /> <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> <br />MONITORING a HOLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />I] EXTRACTION r] AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL I] PVC G OTHER: <br />n VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br />0 AIR SPARGE/ OZONE RPUSH POINT (GP or CPT)GROUT SEAL PUMPED: B Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />NNSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Negtr Ce r» I rir wash r % i, evireoire <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH Li 5 Fr [:, BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED X10 (if YES, list specifications in comment section) <br />COMMENTS: <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 Ordinances, Rules and gulations, and all applicable California State Laws. <br />Signed Title/Company c. &lea- 4 yers <br />ACCOUNTING ONLY: AID# FAC# <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE T - - sly., T # INVOICE <br />35D1 SI. /010 4th 11. 1 <br />SR# 003 to tio ".. <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br /> <br />9 <br />