Laserfiche WebLink
r ? 18 CAMBRIA 1?0? 935 6649 P.02/02 <br /> WEL, PERMIT APPLICATION F �RM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) SNIT I1! <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 0 � � <br /> r- A <br /> NO -RE t V <br /> / <br /> R ES 1 FROM 18 <br /> Application is hereby made to San Joaquin County for a permit to constrict and/or install the work described Thm apptrcatron I$mada in compnerc*with San <br /> Joaquin County Development Title,Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location �AP5a5r�eCesls#ars <br /> ney. <br /> FROPERTIf <br /> Owners o,/ !f ZfSAddress A o Bo>c H991clty2�E 1-469 / ZjP2Z /o Phone#.S6? C9$-9SQC <br /> C»57 Contractor City N�+r-f.�►az 7553 t.tC# Plmrre 4z� '�f3'S��a <br /> Consultant/Sub u:,a,w, ress? r 5 _ C ,tJc#F6- 42 Phorte�! -C� X33-� / <br /> GIs Coor"tes x .Y ,Township Range Sectfo <br /> WORK Ig 13E PERFORMED, <br /> ANEW WELL I BORING (CPT,GEOPROHE,WDROPUNCH,HAND-AUGER,OTHER°) 11 DESTRUCTION (choose We below) <br /> >ff SOIL BORING U OVER-BORE. DIAMEf'ER <br /> ;ff WELL N .5- - -z- 0 PRESSt.IRE GROUT <br /> 11*othar GROUT SPECIFICAMONS <br /> COMMENTS <br /> TYPE-OF WELL IS ALtMON TYPE_ CC NSTRI)nON SP <br /> ECtFICATI4N3 <br /> MONITORING -gHOLLOW STEM DIA OF BOREHOLE—L= [)MULTIPLE CASINGS 13 MULTI -EVEL WELL.CASING DIA, /y <br /> B EXTRACT1014 AIR HAMMERIDRIYEN CASING THICKNESS-Sc- TYPE OF CASING Q STEEL ,' PVC Q OTHF-R <br /> O?OR MUD ROTARY DEPTH OF GROUT SEAL `PREMIE TYPE TO BE USED U AUGERS ) '1rtOSE <br /> R SPARGEI OZONE JWUSH POINT(GP or CPT)GROUfF SEAL PUMPED , Yes Q No (NOTE: MAXIMUM F7:Z <br /> E-FALL DEPTH IS 301) <br /> SOIL BORING CP7r n HAND AUGER GROUT SPECIFICATIONS <br /> Q O'C'HER. w- „WR OTHER APPROX RORING DEPTH Z-B5', I- $S P 6ffiOLTED TRAFFIC BOX Of 11 STOVE PIPE <br /> i CONDUCTOR CASING PROPOSED V YES,list spe fiitabons In comment section) <br /> I <br /> COMMENTS. 3 c�c E s- Z(S G 5 f ( - S6 t - C.P7 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done In OCcordance with San Joaquin <br /> County Ordlnanc s Rules d Regulations,and all applicable California State Laws. ff <br /> Signed x TltEe/Corriperty f0!'t.,� �C4 t�rl <br /> Print Name 9h4Nei Dale 1.0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z �� C� spet'— [u/ <br /> WORK PLAN DATED: 03 <br /> Application Accepted By Date Issued _ �( 3 _ Am CJIQ <br /> CP+}tit Inspection BY Date Final Inspection By Date <br /> Dsslru;slon haspection By Date <br /> COMMENTS I COHDt WNS: <br /> OUNrTING ONLY. AID# FAC# <br /> CODES FEE INFO AMOIJNT REMITTED CHECK* REVD BY DATE PERIIIIT I t3ERVICE RLE] <br /> X50 �[ g I�• 3 ' sR# 6703591.2-o <br /> C-57 WC -WAIIfI:R C-57 Letter of Authorization to sign permit Encroachtt=t <br /> TOTRL P 02 <br />