Laserfiche WebLink
Sent By: Toxichem; 510 595 1288; Apr-2r-02 8:08AM; Page a <br /> Drnzarinn,t U8:54 20946! FIFTH FLOOR PACE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> A Iicaeon is hereby made to San Joaquin County for a Permit to mnstrued and/or install the work desatbed, This appliwGon Is made In mmpiianco Wim San <br /> Joaquin County Development Title,Chapter 9-1115.3 and.the Standards Of$an Joaquin County Public Health Services.Environmental Haam Division. <br /> WELLLooation,�l rl d Q <br /> Assessor's) ../� a� <br /> 't' Crosti Street Ci oL -rt% zip�,,'� 3 ParCgl#_lsL�....5��_._._ <br /> PROPERTY Ownar�[-.r-t' c"�7'f�i"'(.-c�`h�rAedrcas7?�'Z tl�l. CiH`�"L c" Zlp ,1 = Pnone#;n-1444-0 't6 <br /> C47 Centraclof LLLih Addressg5L.) Anr Gil! a>-r nsZi <br /> epig5"i..it,'jL[r 5 Phon.x <br /> �CC <br /> Consultant!Sub Cunlractor _ S�_Adtlresa)) �ir'h�-e�!� �& City far LicR Pnonen`_a-`L�3-l'a55 <br /> 019 Coerdlnates:X .Y ,Tawnshlp Range 8mcliun <br /> WORN TO 13E PERFORMED: <br /> MEW WELL I BORING(CPT,GEOPROBE,HYOROPUNCH,HAND-AUGER,OTHER,) 0 DESTRUCTION(Choose type below) <br /> D SOIL BORING D OVERBORE <br /> *QUELL a L.I D PRESSURE GROUT <br /> 'Other: Grout Speclfieaoons: <br /> commENTS:a,-ia � a r"Mit Oc 1'�UT75T L fl�',•wr.pV\t T- j`1W-'l, „_ ISZ.. CL.b <br /> TYPE OF WELL - INET 71 E CONSTRUOTION SPECIFICA110NS ,r <br /> ,, d NITORING - ?FIOLLOW STEM DIA.OF BOREHOLE___„MULTIPLE CASINGS7 0 YES NAO WELL GA5100 DIA= 2 <br /> a EXTRACTION DAIRHAMMER(DRIVEN CASING 7HICKNESS5Ch-kC% TYPEOFCASING: OSTEELC MOTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL A- TREMIE TYPE TO BE SED: 'p II <br /> >*OSE <br /> D AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: p Yes jalo (NOTE: MAXIMUM FREE-FALL.DEPTH IS 30') <br /> D SOIL BORING D HAND AUGER GROUT$PECIFICATIONS:9S l -c_ I o t-r'E <br /> D OTHER: B OTHER APPROXI BORING DEPTH_ 35:� 1_71FD TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? L (irYES.iistspeCificationshAM): <br /> •COMMENTS:.,. As��tce imet -r r. ��Ik AS i C, I l '-Tv <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKINQ HOURS IN ADVANCE FOR ALL REQUIRED 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 Or i kce-s, Rules andRgulations,CPrint NG'-_[,a C l Da L <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PIAN DATED: <br /> Application Accept*C SYIJ �O� w` —Oale Issued %�40Z -Area 01 Cvw_� 3 <br /> Grout Inspection By_ 3OTOl__Finallnspsction By .,-_Date- <br /> oestnxton Inspection fly _ Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEEINFO AMOUNTRFMTITED CHECK! =BYDATE PPRMRiSERvICEREQUEST# INVOICE <br /> C-57 WC_WAIVER C-57 Letter of Authorization to sign permit_,_. Encroachment doc_ 9/27/00 <br />