Laserfiche WebLink
0023/4006 11:25 9253130 02 GREGG DRILLING PAGE 02 <br /> 08/23/2005 09:54 209 <br /> 433 EHD 10 PAGE 02 <br /> San Joaquin County <br /> Environmental Health Department � <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95 g <br /> 202 MITA SITE <br /> ` (209)468.3449 Fax:(209)468-3433 Web: WWW,9j9OV,or9/ebd ATION <br /> UNIT IV <br /> Well Permit Application ryyp�a, Q <br /> NOM-REFUNDABLE PERMIT'M(PIRES 1 YEAR FROM DATE ISSUED LW D <br /> Application is herahy matla to San.waquln Courtly for a permitt0 construalandlor Install fhe wbr{(degorjpad. Thb appliestivn�K U <br /> JaaOuin County Drjva'opment 7'INe,/C+hapter 9•1 t75.3 and the Standards of$nn Joaquin Cwnty Envkom ontal Health Dapgt <br /> WELL Location�i/31 P4,tf%G�QJN./14.q Crass Sheaf � M ��HT <br /> e.y, OldZ!'+p�..,7 <br /> P90PERTYPa�elxa4h..Hb`t-I ' <br /> Owner •h+ T �Af�������r��,r 7J,r� d�r�ryss 'G l6j `.tilt`c.f}.�rC Clty_.$o/a� L� PI1Cna# ]V�4 <br /> C-57 Convactw *Ug,LLlc/ � m7dmx,Awr% Hn Jfo e!•r' le# eie Q2!}^-313 v o <br /> � "� city �rp9 <br /> Addre <br /> onsulta swbCntrJ^6..a.�r7i <br /> d nVr <br /> _ $sLlo- :mac s14're sn -lac# Phone# O'7 7-9 �.?3(y� <br /> GIS Cootdlnatoe:X� _ ,Y ,Town 1p Range serer <br /> WORN TO BE PERFORMED• <br /> KNEW WELL I BORING (GPT,GEOPROBE,HYDROPUNCH,WWD-AUGER,OTHER? O OPSTRUCTION (dtoose type below <br /> o SOIL BORING re p OVER-BORE. DIAMETER <br /> DWELL# hLj 1r <br /> (],ntlter Q PRESSURE GROUT <br /> CCMMEhITS� <br /> GROUP SPECIFICATIONS <br /> TYPE OF mnl, INSTALLATION TYKE CONSTRUCTION SPECIFICATIONS <br /> kONITORING HOLLOW STEM DIA OF QOREHOLE� MULTIPLE CASINGS 0MULTI-LEVEL WELL CASING DPA: JJ <br /> V EXTRACTION U AIR HAMMERIDRIVEN CASING THICKNESS � YO�,,TrYPE OF CASING; p STEEL A`AVC ]]OTHER: <br /> n VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 2e9:.TJ TREMIE TYPE TO BE USED:XUGERS p HOSE <br /> C AIR SPARGE/OZONE p PUSH POINT(GP or CFT)GROUTSEAL PUMPED: I7 YOS No (NOTE:MAXIMUM FRAE-F' ALL DEPTH Is 3o') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS = Cti <br /> 13 OTHER:__. n CTHER.. APPROX,BORaJG OF-PTH 4'_S kBOLTED TRAFFIC BOX or 11 STOVE PIPE <br /> I CONDUCTOR CABIN PROPOSED_ &C-192— r B YES,Ilsf s e <br /> � � J PdB//t�`fions in canmerttaccfiotl) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS, <br /> U WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS: <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Order igan�gS I and ations,and all applicable Callfornla State Laws, <br /> ergnmd �r,/G/// f�^[— rrtlolCompeny a <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV`FILE,ADD SS: 6 13 1 SPL <br /> WORKPLAN DATED: _�- <br /> Ppplkallen Acamptad ey�,,,j H Date Issued Q- Z3O <br /> Arm 6 Z.L <br /> Grout Inspection BY Date F•dtal IrMMO an By, p� p <br /> Oasuuctlan I • By Date <br /> COMMENTS f CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE mFo AMOUNT REMITTED CHECKx RECD BY DATE PERMIT)SERVICE REQUEST# 1NVOJCE <br /> 3roI gq.00 Zo3so (� 81Lslo6 3R# 79q <br /> C-57•__ WC -WAIVER_ C-57 Letter of Authorixation to sign Permit____Encroachment docu <br /> E1029-02-001 <br /> 6=04 <br />