Laserfiche WebLink
WELL- ERMIT APPLICATION FILM ; �. : <br /> ..�. SITE <br /> SAN 36A&IN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202. . W L <br /> (209) 468=3449 <br /> . JAN 15 2003 s <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED lull a <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicaiibrENVJW i#,ftTiM jt+�an <br /> Joaquin County Development Title,Chapter 9-1115.3 nd the Standards of San Joaquin County Environmental Health Departmw RUICES <br /> WELL Location 67�66 Cross Street�al' Ci Zi � <br /> '�-[�O �� ��i...._..� ty J �c- Y� p�'2,� Parcel# <br /> PROPERTY Owner._ACA—' 7 0yv4�i` C7 Address,—Mi i 1 P� f ;ty fir, _zi� Phone#q?Z <br /> C-57 Contractor y�1�S_I fri�}2 rVWr Address233 �f Q° City- Zip� 7lic#C�S ,oneL�4CJ <br /> Consultant I Sub Cntr �� Address F-. Cityl�;kc"40c# Phone#C01>9 <br /> GIS Coordinates:X Y Township Range Section <br />—"VSfORK i�=BE-I?ERFORMED - 0's .. � ... ��E <br /> <, ,,._ :rp ,.ter-. _�- .� .._ . 4 <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) T,RUCTION (choose type below) <br /> 0 SOIL BORING# ";;~ VER-13ORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING )J-HOLLOW STEM DIA.OF BOREHOLE G LTIPLE CASINGS?;]]MULTI-LEVEL?Q WELL CASING DtA: <br /> EXTRACTION is AIR HAMMER/DRIVEN CASING THICKNESS TY/PE OF CASING: ©STEEL 1]PVC ©OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE BUSED: WAUGERS 0 HOSE <br /> a AIR SPARGE/Ozone 0 PUSH POINT GROUT SEAL PUMPED: kyes p No (NOTE: MAXIMPM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING p HAND ANGER GROUT SPECIFICATIONS: <br /> 0 OTHER: !1 OTHER APPROX.BORING DEPTH �LT-_ 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> !r <br /> CONDUCTOR CASING PROPO ED? (if YES,list specifications here): <br /> *COMMENTS: ` 4 U f� vpv F <br /> II!Il <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 /> s. <br /> I hereby certify that I have prepared this application and that the work will be donein accordance with San Joaquin <br /> County Ordinance� , Rules and Regulations, and all applicable California State Laws. <br />„Signed x..N - .— --" TitleiCompany'"` rl "C � <br /> Print Name—W,G l���w.�C/IYj(Q1 Date <br /> DEPARTMENT USE ONLY qSITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> pted By <br /> 7 a IApplication AccDate Issued ;. f <br /> Area i <br /> Grout Inspection 8yDate Final Inspection By i� .. Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: Ili ry`lil u; i <br /> ACCOUNTING ONLY: AID# y�i;: <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Sd ( 004 I��o .,;� <br /> C-57 WC -WAIVER— C-57 Letter of Authorization to Sign permit Encroachi'nent doc 8/29/02 <br />