Laserfiche WebLink
,. SAN JOAQUIN COUNTY <br /> ` ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Tehp/Ione:(209)468-3454 Fax:(209)468-3433 ~:www.sjgov.o4ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES f YEAR FROM DATE ISSUED <br /> Appicabon Is hw"made to San Joaquin County for a permit to construct andfor WmW the work descibed. This appicedon is mode In compisnce whh San <br /> Josquin County Dereiopm d TMMe,chapter 9-1115.3 and the StivIdards <br /> l of San Jo"An CaaMY p Hm W DepwIltnerk <br /> Was Loc.Non 351 ov r l�uJ sti>jet T city C�s zip 9s3 g5 ei s W'o r <br /> C r A 4 'S-" Address 0. By/� ZO`t g Cuy oc kfo il zip95 2O 1 Phone: oq 9 g-3(530-) <br /> C.w corrtr-w fc rl Z /;c 5 : S it A cry WhJ mp 57 6 i k: i'hone <br /> e e60 36CD <br /> coesultawtl&rb C Nv a h�a m-,& Address 1000 tiro 4 6 c7x� QAkIA*w( Lie* Phone 5 i—/ ,S r, <br /> GM Coordirmas:X Y Township Range section <br /> VIM TO BE PERFORMED: <br /> lNff (CPT.GEOPROBE.HYDROPUNCH.HAND AUGER OTHEIr) ❑DEffnascIrm(CHOOSE TYPE BELOw) <br /> SON.80mm '?Ivo GeDPR p�3e SOIL XR/kVS ❑OVER4)ORE OLAMETER <br /> 0 ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSWS DETONATING CARP <br /> COMMENTS: <br /> Cl MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CA8NNGS❑MULTI-LEVEL W61 CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING,THrK ESS NA TYPE OF cAsNNG:o SfaEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT sEAL%ft/de g E TYPE TO BE USED❑AUGERS)�Hmi—aP VC <br /> ❑AIR SPARCaEIOZONE O PUSH POINT(GP OR CAT)_GROUT SEAL PIMPED:❑Yo No (NOTE:MA)MIN FREE-FALL DEPTH la 3W) <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECPICATiONS �D r7/a n c t?-"e,7t <br /> ❑OTHER ❑OTHER: APPROX_BORING DEPTH SD -FQ e r ❑BOLTED TRAFFIC BOX Ott ❑STOVE PIPE <br /> CONDUCTOR CASINO PROPOSED p VW IN sped4mou in mimick wclfanl <br /> COMMENTS: <br /> NOTE: OFFSITE I3OR*WS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 Notm NOT=Watwm FOR mapecTum <br /> 1 hlralq 1 1Mt no work wS be doves I accewdmm wit Sm Joa rAn Cm*Ondlr mme,Rinds and <br /> s+9ned Title/Cornpany �o Q. mo /C- <br /> Prtrrt Name 1 GL4/H I` Dale <br /> J NT <br /> USE1O-NLYo <br /> SITE MAP IN UNIT TV FILE. <br /> WORK PLAN DATED: -)--o 0 <br /> APPLICATION ACCEPTED BY DATE ISSUED G / l V AREA q— <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> ACCOUNTING ONLY: AID i FAC f <br /> PE COOE5 FEE NFO AMR REMFTTED CHEM# e RECV'D BY DATE PERIM IISERVICE N VIV�OICE <br /> o� 89 8�- 107c,5 a 1�IG !i, ,e sm 6o2y4 <br /> C-57 vc C57 LETTER OF AUTHORIZATION TO SIGN PEMOT ENCROACHMENTDOC <br /> EHO 29-01 10rAW WELL PERMIT APP <br />