Laserfiche WebLink
05/08/2003 10:51 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA-, 95202 <br /> (2(39) 468-3449 <br /> NON-REFUNDABLE PERMIT Ens XPIRES 1 YEAR FROM DATE ISSUED <br /> Applkation is hereby made to San Joaquin <br /> p[e C9.11ry5 3 and the Sta dards of San J aquinl Countykenvi onmental H althcrlbed. This lDepartm nL� e cation is made in Wo sliance with San <br /> Joaquin County Development Tide, p o�-, I Parcel# /qiP/p07 <br /> ,,cc..��� � ) AVE Cross Street(� �/" <br /> N 'W GIH�ToLIC Zlp- " <br /> WELL LOwtlon ZW `�- A R NQyy �J,C• 752-4430 <br /> PROPERTY Owner -SCTGAddres1113 5l5 -G. / L� City a2I ('/C Tip 2 27 Phone y 53D (o _ 4,24 <br /> O M.E *S7�eET Cityf� d zpgS77&Llc# Phone,. <br /> C-57 Con1ractorSo Ic- -r/ N� O'`Ip�•' <br /> Ad 122, 01WNS SNlm Phone 9Z4-04`N' <br /> MIEN Address 77 �/1?GC'ty �Oc# <br /> onsultan 1 Sub Contractor — Sectlon <br /> Townships Range <br /> GIS Coordinates:X� Yom . <br /> WORK TO BE PE FORMED: p DESTRUCTION(choose type below) <br /> 13 OVER-BORE <br /> EW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 13 PRESSURE GROUT <br /> SOIL BORING# SN ou T <br /> W ELL# Grout Specifications: <br /> -Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALS CONSTRUCTION SPECIFICATIONS <br /> TYPE DF <br /> 0 HOLLOW STEM DIA.OF BOREHOLE 8'/•y• MULTIPLE CASINGS?❑YES �NO WELL CASING DIA:Z_._/.uC-J1 <br /> ��,r� TYPE OF CASING= Q STEEL XFPVC t7 OTHER: <br /> I)EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS <br /> R VAPOR 1]MUD ROTARY DEPTH OF GROUT SEALI•S SZ Fee-f—TREMIE TYPETO BE USED: O AUGERS OSE <br /> PUSH POINT GROUT SEALPuhIPED:_Yes. 0 N (NOTE: <br /> MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑AIR SPARGE GROUT SPECIFICATIONS: if <br /> 0 SOIL BORING (]HAND AUGER OLTED TRAFFIC BOX or B STOVE PIPE <br /> Q OTHER__3140T <br /> SE___ t0 Pk,k` CONDUAPPROCTOR <br /> .BORING DEPTH 'e� ,f YES,list specifiabons here):�-- <br /> "(eGh. CONDUCTOR CASINGPROPOSEO.�(� <br /> -COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 Ordi4nCeS, Rules andRegulations,and all applicable California State Laws. <br /> Title/Compan$ignedx atePrint NameE c5 pEPARTMENT USE ONLY. <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: Area ^-D2- <br /> r <br /> rK n [ Date Issued > � <br /> Application Accepted By O: Final Inspection By <br /> C Date <br /> �l�/l� D3_ <br /> Grout Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS/CONDITIONS: <br /> cern <br /> ACCOUNTING ONLY: AIDX INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST# <br /> Yr " S � <br /> / e,- ? /�/C s 2t/`o3 sRte o�338g1 1/z5 <br /> 2� Y81 - <br /> oI " <br /> 7` C-57 Letter of Authorization to sign permit-Encroachment docs <br /> -5wee WArvEI2 <br />