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SR0034567
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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33 (STATE ROUTE 33)
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2900 - Site Mitigation Program
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SR0034567
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Entry Properties
Last modified
11/20/2024 8:59:30 AM
Creation date
10/10/2022 12:58:16 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
RECORD_ID
SR0034567
PE
2901
FACILITY_NAME
CHEVRON OLD VALLEY PIPELINE
STREET_NUMBER
0
STREET_NAME
STATE ROUTE 33
City
VERNALIS
APN
RT OF WY
ENTERED_DATE
7/17/2003 12:00:00 AM
SITE_LOCATION
0 HWY 33
P_LOCATION
99
P_DISTRICT
005
QC Status
Approved
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Tags
EHD - Public
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WELL PERMIT APPLICATION FORM <br />'[?611RC-'W9N t Ai. hEA1.l H SAN JOAQUIN COUNTY <br />` fNV,'1-kONMENTAL HEALTH DEPARTMENT (EHD) <br />03 JUL -9� E) Weber, Third Floor, Stockton, CA., 95202 <br />b (209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Ibor1 N6-) I- Assessors <br />V_1GdLocation �J&IAi U 33 Cross Street - city V'Q'YVIa lS Zip��33� Parcel# <br />/pV - tz� tEYI 2v9-- �/�-G/S7 <br />PROPERTY �wner I ll� I Tu 1 Yt 11b �(P{ G� -L[,a r Address Ici7 (p hayfrr IA1.1 city, C� rUyl Zip 1 5� Phone# <br />—v <br />b�I'r%/�n qio l +-� 9d I�rhnrZ Oj #555 4195 51t - <br />C-57 Contractor �� (r Address City Zip Lic# Phone# <br />onsultant ub Cntr �C.614cjfU� 1�61�1SU lwfsAddress ic1 webSicrSt) )Z Fl City 1ktk1ard Lic# N Phone /b -(cLn3 `flGt� <br />GIS Coordinates: X Y Township °� Range Section <br />WORK TO BE PERFORMED: <br />fl NEW-WEL-L / BORING (CPT GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) Q DESTRUCTION (choose type below) <br />SOIL BORING # jinx -4Q I G 0 OVER -BORE. DIAMETER <br />0 WELL # $ PRESSURE GROUT <br />0 "OtherGROUT SPECIFICATIONS <br />COMMENTS: i+_ r IF 11 r I A wed kM (,oi Ivor IM!� ��L�Irrl"g stn fh.nGc•hrr,P*T n- e Zni dr t� I ()113-losd -Oa 0 a �0 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONSN" I,ue U iJMSi1' ri- d <br />0 MONITORING .XtiOLLOW STEM DIA. OF BOREHOLE_L�t 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS �J PI TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: A/94 <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL titII 6 Lkt r I TREMIE TYPE TO BE USED: 0 AUGERS 13"HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: '0`Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: [, OTHER__ APPROX. BORING DEPTH fjD_ _ _ 0 BOLTED TRAFFIC BOX or -0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS:I, t!45 Wl-h1 11b1`r+A4rAfl�6.I IIIIN4 ,(AI-Pti' 4pf 11 �C,Vb Q i!UIyOL,9a-kr SQ1Nt�iF''- <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />county �inances, Rules and Regulations, and all applicable California <br />State Laws. <br />Signed x Title/Company✓" / <br />PrintN,me y e17n1jq JIM0117-6 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: C✓ kU Q-C-(� WU f, <br />Application Accepted By KAA� Date Issued�/TII Area <br />Grout Inspection By w Date /Ci0? Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE EST # <br />INVOICE <br />C-57 WC WAIVER_ C-57 Letter of Authorization to sign permit roachment docs' 9/30/02 <br />
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