Laserfiche WebLink
Date Destruction Inspection by <br />HYDROPUNCH. HAND-AUGER, OTHER') DESTRUCTION (choose type below) <br />C OVER-BORE. DIAMETER <br />U PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />L'.111) 29-U2-Vil <br />fir2.2/04 <br />C-57 V. WC -WAIVER C -57 Letter of Authorization to sign permit.' <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: wvvw.smov.orgiehd <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES YEAR FRON DATE ISSUED <br />st., rinip, Pr) .„, tunjy,,emg_Aptrir <br />C-57 Contractor <br />Consultant / Sub Cntr <br /> <br />GIS Coordinates: X <br />WORK TO BE PgRFORMED: <br />7,14IIEW WELL / BORING (CPT, <br />OIL BORING *_2 <br /> <br />WELL* <br /> <br />rOther <br />COMMENTS: <br />TYPE QP WELL I1STALLA.T1ON 1Y PI CONsTRLIDTh2ly SPECIFICATIONS <br />II MONITORING 13 HOLLOW STEM DIA OF BOREHOLLI. 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION fl AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a sTai. a PVC u OTHER: <br />0 VAPOR 1) MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO SE USED: LI AUGERS 0 HOSE <br />U PM SPARGE/ OZONE y PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a YO6 0 NO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />X SOiL BORING n HAND AUGER GROUT SPECIFICATIONS <br />1] OTHER: 0 OTHER APPROX. BORING DEPTH Li 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br />CO DCTOR SIN PROPOSED (if YES, list &placation& In comment sect.ion) <br />COMMENTS:-&—a6 Lbwilit)c,- sill <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 Ordinanc ,la nd Re ations, and all applicable California State Laws. <br />Signed x el'14/.:Li ) <br />Print Name eh/.AP Ai", V,,, fa17- , <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: /.2--5-7 <br />WORK PLAN DATED: <br />//70 r Cir 9//4 <br />Date j /0'6 <br />Application Accepted By Date Issued <br />Grout Inspection By Date ,Final InspectIon By <br />kea, <br />Date (0 -(2 "06 <br />COMMENTS / CONDITIONS <br />The/COmpany <br />ACCOUNTINGONLY: <br /> Asnmenv <br />All::* FAGS <br />PECODES FUEINPO AMOUNTREMaTED CHECK* REO,DBY DATE P IT/SERI/ICE ESTO INVOICE <br />22;) ------ CiA>tt -72)-'; SUO e90371 <br />Application Is hereby made to San Joaquin County for a permit to constnJ ct and/or Install the won( described. This application is made in compliance with San <br />Joaquin County Development Title, hooter 9-1115.3 and the Standards of Sort Joaquin County Environmental Health Depersnent. <br />WELL Location (Eein <br />PROP <br />Owner Addressit18)- S • Meintr`C-•City VJ 717 <br /> -1\kle-1)44 City <br />Range <br />_Zi17121111Phonet$ <br />PV531.4 lin2S-Ph one <br />-ge2a3 <br />313 -SX 0 <br />7-3'1o7) <br />TOTAL P.02 <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />- <br />Phones* <br />Section