Laserfiche WebLink
11/21/2002 13 25 2094683433 FIFTH FLOOR PAGE 02 <br /> "'y,LS�.�gnd t3 Sb LI'J740C343J riff rn rLkmxN .... <br /> � ,� �<< WELL PERMIT APPLICATION FORM s�rE <br /> fM�TiGATrON <br /> SAN JOAQUIN COUNTY <br /> NIP `�-'ZV"� ENVIRONMENTAL HEALTH DEPARTMENT {EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA,, 95202 <br /> (209) 468-3449 <br /> p�MEN <br /> NON-REVUNDABLIE PERM P1RE3 i YEAR FROMbA�ISSUED <br /> plication lS hereby made to San Joaquin County for a permit tD construct and/or install the work described This appliraeon rs made In complranc@ wllh Sar► <br /> irquln County Development Title,Chapter 9-1115 3 and the StandaWs of San Jmgwn County Environmental Health Departrnent <br /> GITl RtGHT5 -,0r-wAY SIFIRMgM Assessor's <br /> Location M o F F k T 8LY d, <br /> C `( of M A NTE CA Cross Street e*kv E N V Ir City M A H T S C A _zp S 33 6 Parret# <br /> Ir <br /> �OPERTY Owner tr ti L t C W o R S _ Address. 100 1 W.CIENTE R 5_1LCrry h A N C r r A ZP �Phona11 7 0 U50 <br /> v LLEY <br /> 7 Contractor fi l5c lr NY. Address39 H E ' LACE civ Rk NCTS zip 95157Uctt 6 86r6rPhone# 207}7- 2-3510 <br /> n3ulrant/Sub Cntr R A M A G L EN V, Address $L 0. � U R j�0 <br /> Gty�Go#RG 6S Phone# t91 C)354'37 Q <br /> Gaardrna�6 X Y Townsh,p Range Section <br /> YORK TO SE-PE R ED <br /> EW WELL(BORING(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER OTHER-) Q DESTRUCTION(dtoose type bolow) <br /> I SOIL BORING# S 13--9, 0 11 '2 Q OVER-BORE <br /> B WELL# 13 PRESSURE GROUT <br /> Other Grout Sp6e.flw6ons. <br /> MMENTS <br /> E OF WELL 1NSTALIATIONJMI_ LQNST UC N SPECIFICATIONS <br /> kP <br /> NITORING A HOLLOW STEM DIA.OF BOREHOLE 1`M MULTIPLE CASINGS?QMULTI-LEVEL?p WELLCASINGDIA MA <br /> RACTION 0 AIR MAMMERIORIVEN CASINGTHICKNESS N8_ TYPEOFCASING QSTEEL 0PVC IDOTHEROR 0 MUD ROTARY m7rm OF GROUT SEAL TP=2 5 1 TREMIE TYPI:TO BE USED 0 AUGERS 0 HOSE <br /> AIR SPARGE I Ozone @ PUSH POINT GROUT SEAL PUMPED U Yes It No (NOTE,MAXIMUM FREE-PALL DEPT"IS 30) <br /> 10ORtNG a HAND AUGER GROUT SPECIFICATIONS A C N T <br /> __ 0 OTHER APPROX BORING DEPTH .-Z 5` f p BOLTED TRAFFIGBOX or QSTOVE PIPE <br /> ODNDUCTOR CASING PROPOSED? N 0 (of YES hstspecl17aatjons here) <br /> MMENTS <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 /> treby certify that I have prepared this application and that the work will be done In accordance with San JaagUin <br /> :ounty Ordinances,Rules and Regulations,and all applicable California State Laws. <br /> led x <br /> InntName I�m Date-AA—\5— O 'd, , <br /> DEPARTME19T USE ONLY <br /> IE MAP IN UNIT IV FILE,ADDRESS: �92 S MOFFFtT GA <br /> VORK PLAN DATED: "t116101 <br /> Ilicabon Accepted try Dale Issued { 1_� Z 1 i Are;k <br /> ,rout Inspection 8y bate Final lltspectlon By Date <br /> uct,on Inspection By bate <br /> MEN-rs I ComDMONS <br /> ACCOUNTING ONLY AID€3 carr <br /> CODES FEB 111111111 <br /> INFO [AMOU7NF REMITTED CHECK Al RECD BY DATE pERMrr l SERVICE REQUEST�! INVOICE <br /> car] 3 0 l{ 2410 R>a <br /> �7� Wr:_ _.�WAZVER� C-57 Letter of Autherizafion to sign perrnrt____Encroachment dac— <br /> 6l9/02 <br />