Laserfiche WebLink
- ADPL. CATION FORM <br /> WELL PERMIT <br /> ' MITIGATION <br /> l t� SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 /� rS <br /> V <br /> NON-REFUNDABLE PERMrr EXPIRES 1 YEAR FROM DATE ISSUED <br /> plication Is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in oompLance wrth San <br /> aquui County Devei meat TIM Chapter 9-11 3pattd the Standards San Joaquin County Environmental Health Deparhnent. <br /> Assessoes <br /> Loo�tion �KJz- Cross Sttee City 7�p Parcew f � <br /> c i T, o o T eGK roil Address Al.EL DaRAO 0 City Si ocK7' Zjp`�5ZO zPhon��ioA 937, F5'/I/ <br /> rp-oElRTI Owner 0 AF-iO c�Im l ROOK a 2 4 <br /> -37 ContractDrC D.4;���%� Address'o3.� Ori C, C: c1C city c ap-'- ' 1l�7! 5� Phane#�`If6��3 -/!b9 <br /> lonsuttant I Sub CntrA.G.1± Address>5 s city SToc K7'rt�l�c. t0 a Z-2- ?' a-�b <br /> Phan Z c Yb <br /> 31S Coordinates X Y Township Range St ctcn <br /> RK TO BE PERFORMED- <br /> E1IV WELL/BORING(CPT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION(choose type lselaN) <br /> 1] SOIL BORING# Q OVER-ECRE <br /> ,AVE3l# Mw-t5, W• W` Lv•�fS�Nly� 13 PRESSURE GROUT <br /> er <br /> Grout 5peat3cations, <br />�CMMENTS SEL A 4 C I T a P 5 Tn� T <br /> PE 4F WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �1/ <br /> ONITORING iOLLOW STEM DIA OF BOREHOLE S muLTIPLE CASING I ULT/-I.EVELI WELL CASING CCA <br /> 3 EXTRACTION 17 AIR HAMMER/DRIVEN CASING THICKNESS �{-a--_TYPE aP GASI GEL (]PVC OTN3=r'�� )~1 c�✓ <br /> I)MRa MUIJ ROTARY DE=IT-t OF GROUT SEAL 3 b F+ , TREMIETYPE TO BE USED 11 AU ERS 0 HOSE <br /> AFWPARGE I Ozone p PUSHY POINT GRQUT SEAL PUMPED fes No (NOTE_ MAX]MUM FREE-BALI. DEPTH IS 30') <br /> 1 SOIL BORING 13 HAND AUGER GROUT SPECIFICATIONS - _ <br /> OTH CTHER APPRL3X BARING€7pT1-1BQL71wi7 TRAF=3C BCX or STOVE PII~E <br /> CONDUCTOR CASWG rROPOSED��_(If YirS,Ilst speafirattans here) <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 /> hereby certify that I have prepared this application and that the worts will be done in accordance with San Joaquin <br /> aunty Ordinances., Rules and Regulations, and all applicable California State Laws. <br /> G, <br /> ,gned x <br /> Title/Company, �a 1 <br /> Ent Name t J. Cve;&Z <br /> �- Date O O <br /> ///D,EPAARTM T USE ONLY ^� <br /> .-I&Ar% R.I ,:.iiT n•C11 c AnIWi?FCq• / / / irW4 <br /> WORK PLAN DATED` r! 0 1 fyyy��/ <br /> /%�� r An;a <br /> Date Lssued 4 /� <br /> pll�tiorm Accepted By — _ -- <br /> Grout inspection By Date Final Inspection By Date <br /> estructon Inspec k n By Date <br /> TS I CONDITIONS. <br /> A UNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT tilrMlT"f1:D CHECK# REC'D BY DAIS X <br /> RZ <br /> WVOtC>=Z1to-'�5C-57 W( -WAIVER C-57 Letter of Authorization to sigh permith8/29/OZ <br />