Laserfiche WebLink
05/10/2004 14:43 2094683433 FIFTH FLOOR PAGE 02 <br /> D, V D WELL PERMIT APPLICATION FORM SITE <br /> MAY 2 1 2004 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PFw,;1IT/SERVICES (209) 468.3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM PATE ISSUED- <br /> Application is hereby made to San Joaquin County for 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-AssessorR <br /> WELL Locatnw,'V90` dc, f; AV,4,0-1.1/V'6 m;s Street 1 gh4cy HCVD- City 1,e/{GZip $ -;'& Parcelk.C.O.T� f4' <br /> PROPERTY Owner eF TiZ qe-9 Address s"// 1J. MEANT LINE FO.City,(KA-C V Zip jjP5 (QPhone7�ZO9��-;/' y�0p <br /> C57 Contractor( �CAO'5 'DR4l1/4 lAddress 3 60 3 Z AAAI C- 61R- City CommayA Zip 1S-�WZ Lic#iy?-VD Phone# /b 38- 110 <br /> VA <br /> Consultant/SubCntr Cr�IZ _ Address-46/x- �i� R� RP•'*IWCItY9QNC/fs lc# Phon-yy/!s ?* -oy., <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED; <br /> p NEW WELL,/BODING (CPT,GEOPROBE,HYDROPU NCH,HAND-AUGER,OTHER'} Cl DESTRUCTION (choose type below) <br /> Il SOIL BORING# 0 OVER-BORE. DIAMETER <br /> O WELL#-3 /YJr�a e4�''ti I7 PRESSURE GROUT <br /> 11*Other GROUT SPECIFICATIONS <br /> COMMENTS: roiz �unr7„1ArErz Sn�t+at 11`1L IX)I U BE ,tr s i�cy4FP '-5AM E TAY. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTTON SPECIFICATIONS <br /> IuIONITORING HOLLOW STEM DIA_OF BOREHOLE n MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA:__. <br /> Q EXTRACTION 1]AIR HAMMER/DRIVEN CA51NG THICKNESS SGM• `10 TYPE OF CASING: n STEEL A PVC a OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROAT SEALki 1A TREMIE TYPE TO$E USED: AUGERS o HOSE 1pt <br /> n AIR SPARGE/OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPI p Yes d No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING 1)HAND AUGER GROUT SPECIFICATIONS lU E&t M E%n1 i <br /> a OTHER; n OTHER APPROX.BORING DEPTH_L 5" o BOLTED TRAFFIC BOX or I1 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED A1-, (if YES,list specifications in comment section) ` <br /> COMMENTS: C�m goUT WILL F9 - FALL UryLt"-5S 24 regT c.- LAD= SJR ZLcU6H, THeIv T+eEM1p"- <br /> NOTE: OFFSITE 13ORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinan s, Rules and Regulations,and all applicable California State Laws. <br /> Signed r Titie/Company "t �I EKTIS c� �` <br /> Print Name �� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: rlJA L. r M r 0 �1 i <br /> Application Accepted By Date Issued <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date- <br /> COMMENTS <br /> ate �J <br /> COMMENTS t CONDfT10NS: /M-f/ NI�ll11D� <br /> FACCOUNTiNG ONLY: AID#i FAC# <br /> DES FEE INFO AMOUNT RFJYIITTED GHEGK# REG'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> pI C3 - - �8V1 39 � �-1 r7 sR#60 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign p rmit Encroachment doc 9/30/02 <br />