Laserfiche WebLink
- R SITE <br /> FVR M <br /> WELL PERM APPLICATION:: <br /> I-'IGATION <br /> > W�� �J L�� TH SERVICES UNIT. <br /> SAN ,IOAQUIN COUNTY PUBLpIV1SION (PHS-END) <br /> ,SAN 3 Q. ZOOZ ENVIRONMENTAL- HEpL.TH CA,, 95202 <br /> Stockton, COPY <br /> 304 E:Weber, Third Floor,- � ILE <br /> ENVIRONMENT HEHL-TH (209) 468 <br /> PERMIT/SERViCESRolvl DATE IssvE� <br /> NOABLE PERMrr EXP14tE5 1`lEAlt This a}sp <br /> Iicatian 9s made in c�mpGance with San <br /> NON-REF17 ironmenta ��DivisionO <br /> for a permit to construct and 7or install ttse v+a Puti�Heaith Services.En <br /> Joaquin County uirn County <br /> Application is hereby made es <br /> San ter 9-1 i 95.3 and the Standards of San Joaq Zip rw �P <br /> Joaquin CauntY DevelopmentTtie,Chap 7"nLuunJfi ;City S (•�(, <br /> S b�At� Cross Streeta.1 1 0 r- 2 "f Phane>r <br /> i Location Address��b� � l 'City�N <br /> g� 7Pt1an <br /> PROPERTY Owner 1 ---CityZ <br /> i��.r� f r i t 70 rl!lA —Address b r! Inc# d Z Z Phoned 6 <br /> C47 CantracWr �f CitY — <br /> V� Address Section - <br /> Consuttant 1 Sub Cantmctc Range <br /> e Y Tawrnship <br /> GtS Coordinates:X e below) <br /> Q OESTRUCTION(choose type <br /> g"W <br /> ERFORMED- - D-AUGER,SEW) U OVER-SORE <br /> BORING(CPT.G OIL BOREI HYOROPUNCH. # . .x Q Gf P{ SSURE GROUT <br /> ELL Specifications <br /> Grout Speci <br /> ,fie <br /> COMMENTS: " " <br /> p r� <br /> f ON SPEC <br /> IFICAA71ON <br /> 5 <br /> E, TYPE L INSTALLATION TYPE ,,, CONS74�UCTI K 4 f. �ULTIPLI=CASINGS? YES [j i�0 " WELL CASING DIA�� <br /> OLLOW STEiVI DIA.OF BOREIOIF <br /> Q MONITORING a TYPE OF CASING: i7 STEEL-: PVC [10THER <br /> [l EXTRACTION AIR HAMME�3RIVEN CASING THiCKNESS� — <br /> XVAPOR Q MUO ROTARY DEPTH OF GROUT SEAL <br /> P16� TREMIE TYPE TO BE 1751=D:��AUGErZS Ij f-iOSc <br /> AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: /&Yes :a No (NOTE: Z UM FREE-FALL DEPTH IS 301 <br /> [I OIL BORING U HAND AUGER: GROUT SPECIFiCATlONS: OLTED TRAF=IC SOX of Q STOVE PIPE <br /> ll OTI_IF O�}�ER APPROX-BORING DEPTH 5 <br /> CONDUCTOR CASING,PROPOSED? ' (if YES.list speciricadonshere); � %1 L <br /> / <br /> NOTE_ OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHM�EREPERMITS. <br /> INSPECTIONS. <br /> CALL THE UNIT IV INSPECTOR X48 WORKING HOURS IN ADVANCE FOR ALL REQ <br /> I hereby certify that I have pre red this application and that the work will be done in accordance with San Joaquin <br /> County to n U and egulations,and all applicable California State Laws. <br /> Signed x <br /> Tide/Company <br /> .�, <br /> i fD fo tib <br /> Print Name t6til b7 Cif Date <br /> DEPNTUSE ONLY' <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: -2,7OL p <br /> Date Issued r"` Area 0 a <br /> Application Accepted 6Y x •• °" �• 7J <br /> Date <br /> Grout Inspection By Date F nal Inspection 8 <br /> Destruction Inspeatian By Date <br /> I commENTS I CONDITIONS* <br /> jACCOUNTING ONLY: AID# EAU <br /> PE CODF5 FEE INFO AMOUNT kEMITTED CHECK itEC'D 8Y DATE .-` l REKNIT f 5ERVICE REi�UEST INVOICE <br /> C-57 WC -WAIVER C-57,Letter of Authorization to sign permit - Encroachment dot 9�27I00 <br />