Laserfiche WebLink
07/17/2002 n':53 2094613343f' FIFTH FLOOR PATE 02 <br /> WELL,PERMIT APPLICATION FORM SITE <br /> - <br /> SAN Jo,AQUIN COUNTY MITIGATION <br /> IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FRAM DATE ISSUED <br /> ApplImtlon is hereby made to San Joaquin County far a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San.Joaquin County Environmental Health Department, <br /> Assessor'& <br /> WELL Location ILej n WtS Crass street—_ S City _540c-K-l-on zip E. 3 parcel# X35-��0 IS <br /> PROPERTY Owner 4)Qr4ac '?-AC"cl8 Co Address T-c•�ap)c �iS`��I` Gity ma'adJ� Zip 9q-V-20Phone��'��'2 <br /> C-WContra='TC• Exp\o•ra-- bel Addmss28$3C1nd�r1na�4 AVe_ city: ZipgS745L; �1.S551ophanet 9l6)y3 `/�00 <br /> {+t wq $g1CS�r _ <br /> Consultant f Sub Cantractcr URS Address'787p Cxty k�} 3o?Ci �o.xQ tC# Phone 9� L7q-a�0 y <br /> __ Ir <br />" `GIS Caordfnates:'X -- Y _- -- ._ --,Township .< Range_.__, Seauan <br /> WORK To BE PERFORMED: <br /> NEW-WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) Q DESTRUCTION(choose type t?elow) <br /> (I SOIL BORING# la OVER-BORE <br /> [ WELL# a PRESSURE GROUT <br /> `tither: Grout Specifications: <br /> COMMENTS: <br /> i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> (�MONITORING�3� 1 HOLLOW STEM DiA-OF BOREHOLE MULTIPLE CASINGS?I]YES ONO WELL CASING DIA: 02- f <br /> p EXTRACTION a AIR HAMMEWDRIVEN CASING THICKNESS S;Ft< -�lU TYPE OF CASING: [I STEEL a PVC 0 OTHER: <br /> p VAPOR []MUD ROTARY DEPTH OF GROUT SEAL_ 3•a TREMIE TYPE TO BE USED-' N ALIGERS p HOSE <br /> a AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: ❑Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> n SOIL BORING ' n HAND AUGER GROUT SPECIFICA710NS: Yt L -1 ceryLtyz'i- <br /> I]OTHER: p OTHER APPROX.BORING DEPTH __-12-5 1 M BOLTED TRAFFIC BOX or p STOVE PIPE <br /> �+ CONDUCTOR CASING PROPOSED? 4 (if YES,list specifications here): <br /> -COMMENTS: Phase ttite<<»cam wec-t�, 10an clad 7z§5Dgt-r Srfc � <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. 4:$ <br /> ° <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 Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x Titte]Company 'i f <br /> Print Name rr-__ r U - - <br /> DEPARTMENT USE ONLY. p0 1 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Ot <br /> WORK PLAN DATED: <br /> Application Accepted 8Date Issued ` OO ea - 1 <br /> It <br /> Grout Inspection By ADate Final Inspection By 2` ate _ 4) <br /> Destruction Inspection By bate <br /> COMMENTS f CONDITIONS: f/) X/ 641 <br /> ACCOUNTING ONLY- AID# <br /> =ar^� <br /> Pe CODES FEE INFO AMOUNT REMITTED CHECK:a REC'U 13 DATE PERMIT!SERVICE REQiJEST 3F INVOIGB <br /> C-57_ WC_-WATVER C-57 Letter of Autho i to sign permit Encroachment doc � 1/25/172 <br />