Laserfiche WebLink
01/02/2004 14 53 2094683433 FIFTH FLOOR PAGE 63 <br /> V\ WELL PERMIT APPLICATION FORM SITE <br /> TI <br /> SAN JOAQUIN COUNTY UNIT MITIGATION 4N <br /> ENVIRONMENTAL HEALTH DEPARTMENT (r=1­10) <br /> IV <br /> 304 E Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described This application Is made in compliance with San <br /> Joaquin County Devalopment title,Chapter 9.1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> ���L,, r t Assessors <br /> WELL Location 7��v C��.rr ri '�YQ�[ Cress Street City Zip Parcelfl� � 0 <br /> PROPERTY Owner [ H AsddrressCity�_ZI hone#QA <br /> C-57 Contracto ' I� � � ddress`��W g"eIq Cdymar6ex ZIR �,LIPhone# ?1Sx00 <br /> Consultant/5uhCntrtAlylt�+lGlddress w itylLEC# 830 phone# a}� ZIP <br /> GIS Coordinates x Y Township —IN Range �-� „ Section_ _ <br /> WORK TO BE PERFORMED <br /> FE—VV WELL BORING(CPT,GEOPROBE HYDROPUNCH,HAND-AUGER OTHER') p DESTRUCTION(choose type below) <br /> O SOIL BORING# O OVER-BORE <br /> 1 <br /> :KNELL�p_�Gl�,I`S t a PRESSURE GROUT <br /> 'Other' _ Grout Specifications <br /> COMMENTS r <br /> TYPE OF WELL 1NSTALLATIOF4 TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING �SVOLLOW STEM DIA OF BOREHOLE $ i MULTIPLE CASINGS'a MULTI-LEVEL?O WELL CASING DIA <br /> a EXTRACTION 17 AIR HAMMER/DRIVEN CASING THICKNESS SCk qD TYPE OF CASING a STEEL XPVC 0 OTHER <br /> O VAPOR II MUD ROTARY 015PTH OF GROUT SEAL TREMIC TYPE TO BE USED )$'AUGERS a ROSE= <br /> *IR SPARGE/Ozone o PUSH POINT GROUT SEAL PUAAPED O Yes 'd No (NOTE:. MAXIMUM FREE-PALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS f Ge"am <br /> {]OTHER_ 11 OTHER APPROX BORING DEPTH A 2OLTEO TRAFFIC Sox or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?�(if YES list specifications here) <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 1 ave Prepared this application and that the work will be done to accordance with San.Joaquin <br /> County Ordtna es and Regulations, and all applicable California State taws. _ <br /> Signed xTitlelCompany &;44W <br /> Print Name y rM r r Date_ 17,&� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: e <br /> WORK PIAN DATED: <br /> Application Accepted By ---_Pate Issued, ! <br /> Grout Inspection By Date _ Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS <br /> ACCOUNTING ONLY AID# <br /> CODES FEE INFO AMOUNT REMITTED CHECK# RE 'D BY DATE PERMIT/SERVICE REQUEST# E <br /> a? / (0 3 <br /> C-57 WC -WAIVER_ C-57 Letter of authorization to sign permit Encroachment do8/29/02 <br />