Laserfiche WebLink
03104/2004 15 00 2094680FIFTH FLODR PAGE 03 <br /> 10-24-2800 03 4LPM FROM D TO 15306766005 P,02 <br /> is WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN jOAQUIN COUNTY PUBLIC HEALTH SERVIC � <br /> ENMFtONMENTAL HEALTH DIVISION (PHS-EH; I} ! , <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 4583449 MAR 111 1 ?: <br /> Hd�i-F2EFl3NbA8LE PERMET EXPIRES 4 YFAR FROM DATE Mug <br /> Apprc=bvn m lhcrety Made to Sar,Jeagmfl County fare permst to cansMsct and/or ostall the work described This ap5l 16nlls'made In compr=1746 with San <br /> JoagLdn County Development Title,Chanter 5•z 115.3 and lite Stzrkdan1s 4W/4- <br /> at San`Joaquin County Public Health 5ennc-M 6'3y�'irgnmp,�_II 1OV413 son <br /> WELL LoCat,o A 5}. Crass <br /> Street 4W/f� C7yS6 �&t7P ParneTA ! .d <br /> Pi2QPErtTYpwnper Y7� AAdrA�_. /� <br /> C-67 Contractor fi(1 „ I, dress -550 _�d,,r, cdyg'D <br /> Constlltant/Sub COntractors F-.-my Addres5�l utwrP�sn� Dr '�Ctty Phone#� � <br /> GtS Coard,nates-X._, , . --Y __-- To+ur:ship. -- --x'13" <br /> Bataan <br /> t) "01 <br /> a NEW WELL/BORING(CPT.GEOPROSE HYDROPUnICK HANG-AUGER OTHER1 E3TRUCTION{choose type beio'�+'S <br /> 11 SOIL BORING# Q OVER-BORE <br /> I]WELL# RESSURE GROUT <br /> • ,yr; Grout Speelfeae�on� <br /> COMMENTS Qc v4,W MW_lZ <br /> 'iYIPF OF WELL MALLA_QQN TYPE CONSTRUC'T*N SPL!1CnrATION3 <br /> -thONITORING Q HOLLOW STEM DIAL OF SOREHOLS MULTIPLE CASINGS?l]YES 8 NO WELL CASING DIA; <br /> €�DCTRA9nQN QAlRMAMMFFVDRrV—=+I CAS ING THICKNESS TYPE I]F CASING U STEEL R PVC B OTHEFL�,. -. <br /> • ]VAPOR n MUD ROTARY DEPTH OF GROUT SEAL --.TREtAIE 7YPM TOSS USED, II AL]GERS D HOSE <br /> []AIR SPARGE II RUSH POIbtT GROJTSEAL PUMPED g Yev p Nv (NOTE:MAXIMUM FREE-FALL DEPTH IS 30) <br /> 0 SOIL DOMNIG l]HAND AUGER GROUTSPEOMICATIONS <br /> OTH_RI 17 OT74ER APFROY.-50RING DEPTI t A BOLTED TRAFFIC;BOX Or D STOVE PEPS <br /> CONDUCTOR CASING PROPOSED") (if YES,Itst Specifications here). -- <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PEFZMITS <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPEt;T14NS. <br /> I hereby certify that I have prepares#this application and that the work will be do% in accordance with S*n Joaquin <br /> Cotx*Ordinances, ule$and Regulations,and all applicable California Stato Laws, 4 <br /> Signed x TlttelCornpary-t 7g7 7 <br /> Print Name 5 Dots �L—v—c03 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS'. �Q <br /> WORK PLAN DATED: <br /> AppEicatlon A„ceptod Ey ate issued t r.�.—Area <br /> Grout Inspection i3y Dar$ Frnat(nspechon By,. -----Dasa <br /> Destruc an Inspe=on By f?at2 <br /> CO)IMEHTS/CON DIrIONS <br /> ACCOUbiTMG ONLY AID; <br /> PE CODES FEE NF0 A Ol1NT REMMED CHEGK1t RECD BY DATE PERMIT f sr=P.VICE REQUEST# IN <br /> ��� ff Y b 10 <br /> C-57 WC-WA1VEP,,,_ C-57 Letter of, Authorization to sign permit__..._Encroachment doc_ 9/27/00 <br />