Laserfiche WebLink
111141 EgrjM LL; 04 Lr71:144Gj444 LHU T"H47G UZ <br /> WELL PERMIT APPLICATION FORM SITE <br />' <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> " ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br />' (209) 488-3449 <br /> HD LEP I ISSUED <br /> Appiicatioh Is hereby made to San Joaquin County Tor a permit to oonsbvat and/or irruatl the work described. This sppncation is rnads in compliance Wth San <br /> Joaquin County Devefopriwnt Tttla,Chaptff 9-1 t is-3 and the Standarda of San Joaquin County Environmental FAmIlh Department <br /> Asseaso �� <br /> WELL.Laeatlonss Street � y ty Ts Pars ��� <br />' <br /> PROPERTY OvmerA"/ -_.0-.0 -yet <br /> _ Address +tF�i ,��sr� �Pl�/srQiy TJp�n <br /> C-57 Contractor Address <br /> Conmultant1Sub Cantra*0 drams 9�31�/d'N�MO�!__Cite <br />' GIs coordinates:X— Y Townard Range BaoGon <br /> P <br /> WELL!BORING(C!PT• ,GEOPRQsE,HYMOROPU H,HAND-AUGER,OTHER.) DESTRUCTION(chatype balov�) <br />' SOIL BORING 1M PRSSOROVER-BORE <br /> PRESSURE GRt3lrr <br /> 'Other. Grout spedfica<t3onst <br />' COMMENTS: <br /> EOPwlalt T u Tt y <br /> 1C10NfTOR1NG "POLLaw STEM DIA. OF BOREHOLE tv MULTIPLE CASINGS?O YE6 IYNO WELLCASING DIA: <br /> a WRACrION q AIR HAMMERcrtiVEN CASINGTHICKNESSA$„�— YPE OF CABIN G;. 13 MEL C Ii MER: <br />' a VAPOR MUD RO'T'ARY DEPTH OF GROUT St'_AL�Td-, TgCMIE TYPIr TQ BE U6ED; d AUGEI;tS �J HOSE <br /> G AIR SPAROFF WVSH POINT GROtr SEAL PUMPED; U Yes o (NOTE- MAXIMUM FREE•FALL VEPTH IS 30') <br /> ' .%VOiLUORING q HAND AUGER GRCUT SPECIFICATIONS: 1261 <br />' a OTHt3.R a OTHER,__,. APPROX 13URI NG DEPTH q BOLTED TRAFF=IC BOX or it STOVE PIPE fi <br /> CONDUCTOR CABIN ROPOSED7,A -_- (if YES,Get apedticalio„s here): <br /> *COMMENTS: P!z42 <br /> R tCsin!, �elz <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR NCROACHMENT PERMITS. <br /> CALLTHE UNFT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby oartity that I have prepared this application and that the work will.be-done in sarsardsnce with San Joaquin # <br /> County Ordinances,Rutlos and Regulations, altd all applicable California State I-aws. { <br /> Signed x Tltiefcomparty <br /> r� <br /> Print Nameoat+ <br /> DEPARTMENT USE NL�f <br /> .O <br />' SITE MAP IN tiN1T IV FILE,ADDRESS: <br /> WORT{PLAN DATED: <br /> Appllcvdon Accepted By.—Ally, ''�'t __, .Date lasued 1 b 5 Area <br /> Grout Inspaabon By ate _Final Inspection Sy � — -- <br /> Deatrveton Irwedian By Data <br />' COMMENTS t Gt3NdTTTt7tV8` . <br /> ACCOUNTING ONLY: Not �ar5et <br /> PECODflS RI INFO AMOUNTREMrrrl:D CHECK# REsJ'6BY I DAT9 PERmrrtarltviCEREQUEST 0 WvolCe <br /> 0 C-57, we-WAIVER— C-57 Letter of Authorization to Sign permit Encroachment.daG— ' 1/25/Di <br />