Laserfiche WebLink
05/14/2004 10 28 4640139 ENVIRONMENTAL HEALTH PAGE 02 <br /> San Joaquin County _ <br /> Environmental Health Department F0)�11�1 rc:4 <br /> . 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax (209)468-3433 Web www.sjgov org/&d AUG 3 Q 2004UNIT IV <br /> Well Permit Application HtArM <br /> NON-REFUNDABLE PERMIT EXPIRES 9 YEAR 14101111 DATE ISSUED pERMIT/SEWCES <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work desWbad This application is made In compliance with San <br /> Joaquin County Development TIVa,Chapter 5-7175 3 and the Standards of San Joaquin Counly Environmental Health Depariment, <br /> Assessors <br /> WELLLotw0on Cross Strs@6 le*4k'AA Clry„Sfckf� Zip�Pareei#//D� 1 <br /> PROPERTY <br /> Owne r fZL47714jAddress 2I pR1Phone# <br /> C47 Contractor C&SCAa �"uc# f 79 t'Phonal! <br />' Consultdnt/Sub CntrAdd re , -----— P h a n 1 60Z—Agro <br /> GtS Coordinates X Y ,Tewrishl X jy Ftinge^_A�_ Secbin � <br /> WORK TO BE PFRFORNISD' <br />' OEVM 1NELI-1 BORING (CPT,GEOPROBE,H"YDROPUNCH HAND-AljrER,OTHER") h DESTRUCTION (choose type below) <br /> r SOIL BORING aj]OVER-BORE: 01AAAETER <br /> WELL,0:3 Wi t/ j]PRESSURE GROUT <br /> 4*000� / GROUT SPECLFICA nONS <br /> COMMENTS <br /> SOF 1MF� INSTALLA110N TYPE CONSTRUCTION SPECIFICATIONS t, <br /> 13 MONITORING )<HOLLOW STEM DIA OF BOREHOLE—g XMULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA <br /> a EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS_TYPE OF CASING )rt-'TEEL n PVC Q OTHER <br /> lie <br /> VAPOR 0 MUD ROTARY DEH OF GROUT SEAL TREMIE TYPE TO BE USED ©AUGERS ),OTOSE <br /> XAIR SPARGE/OZONE Q PUSH POINT((3P or CPT)GROUT SEAL PUMPED )(Yes p No (NINE. MAXIMUM FREE-FALL DEPTH IS 301 <br /> Q SOIL BORING p HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER D OTHER . APPROX BORING DEPTH XBaMD TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ,W of YES,list speclrieabon$in oomment section) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPE=CTIONS- <br /> I hereby certify that I have preparers this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules aad R ulatlarls,and all applicable California State Laws. <br /> Scgned x `� r� � Tltle/Cornpetry �'`—� <br /> Print /ems- G�Sdvt _Oise O <br /> Kf <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Data Issued <br /> Application Accepted 13 11.1Cww,.f/{ Date <br /> Grout Inspection gy Date Final Inspection BY <br /> Destruebon Inspection By [late <br /> COMMENTS 1 CONDITIONS' <br /> ECCOUNTING ONLY AID# FACS <br />' CODES FEE INFOAMOUNT REMITTED CHI=CKa REC'b 8Y DATE PERMIT1 SERVICE RERUEST# INVOICE�D� � SR#��96a3 <br /> C-57_._, WC=WAIVER C-57 Letter of Authorization to sign permlt Encroachment dot— <br /> E1-Iv 29-x2 001 <br /> twZ7a0a <br />