SR0054766 - Laserfiche WebLink

Home Browse Search

.: SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE 600 East Main Street, Stockton, CA 95202-3029 MITIGATION �.� Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: wtrn/v.s1gov.orq/ehd UNIT IV WELL PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. / • / (via r!':u T v ;IA 1-4_ - =' Assessor's Well Location r.v,i1 S.tvz7 S�Ju%h Cross Street er City r :h (t) -,Zip V S 2& Parcel # tiz'9 Property„ Owner �;' kIc'l,141 Address CUbt`� "1�``IG� `�"t"�� City Zip Phone# C-57 Contractor i -Z ,4r'u1*1 6"- Address 3, Lu r' J= ! / i 5 y-, I City �.� is Consuitant/Sub Cntr �2' iL�S'r7 Address yrtJ. City I t L7n GIS Coordinates: X Township 1�91RK TO BE PERFORMED: NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') SOIL BORING# ❑ WELL # ❑ 'OTHER COM TYPE OF WELL ❑ MONITORING ❑ EXTRACTION ❑ VAPOR ❑ AIR SPARGE/OZONE SOIL BORING INSTALLATION TYPE P HOLLOW STEM ❑ AIR HAMMER/DRIVEN ❑ MUD ROTARY -11 - Zip �f r` z Lic #r' f� N �I Phone Lic # Phone(2�- i Range Section CONSTRUCTION SPECIFICATIONS DIA. OF BOREHOLE �+ ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: - CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: ❑ Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') ❑ HAND AUGER GROUT SPECIFICATIONS /U "t- ,I /OTHER: 7{.,'`t b d t'J ❑ OTHER APPROX. BORING DEPTH ' ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE -I CONDUCTOR CASING PROPOSED „11AI) (if YES, list specifications in comment section) COMMENTS: NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and Requlations, and all applicable California Laws. Signed 4_y_t.- Print Name 7:� ,c -t 11 SITE MAP IN UNIT IV FILE, ADDRESS: WORK PLAN DATED: APPLICATION ACCEPTED BY GROUT INSPECTION BY v/ ” DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: 01 Title/Company ��,yl,G9+� ��Lr Date DEPARTMENT USE ONLY DATE ISSUED _71316-8 FINAL INSPECTION BY DATE AREA DATE ACCOUNTING ONLY: AID # FAC # - ❑ DESTRUCTION (CHOOSE TYPE BELOW) FEE INFO ❑ OVER -BORE DIAMETER CHECK # RECV'D BY ❑ PRESSURE GROUT PERMIT/SERVICE #, GROUT SPECIFICATIONS t n CONSTRUCTION SPECIFICATIONS DIA. OF BOREHOLE �+ ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: - CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: ❑ Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') ❑ HAND AUGER GROUT SPECIFICATIONS /U "t- ,I /OTHER: 7{.,'`t b d t'J ❑ OTHER APPROX. BORING DEPTH ' ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE -I CONDUCTOR CASING PROPOSED „11AI) (if YES, list specifications in comment section) COMMENTS: NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and Requlations, and all applicable California Laws. Signed 4_y_t.- Print Name 7:� ,c -t 11 SITE MAP IN UNIT IV FILE, ADDRESS: WORK PLAN DATED: APPLICATION ACCEPTED BY GROUT INSPECTION BY v/ ” DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: 01 Title/Company ��,yl,G9+� ��Lr Date DEPARTMENT USE ONLY DATE ISSUED _71316-8 FINAL INSPECTION BY DATE AREA DATE ACCOUNTING ONLY: AID # FAC # - PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE PERMIT/SERVICE #, INVOICE 1? SRcS r`_S7 IA/('. -WAI\/FR R57 I I-TTFR r11- At I I H( 1FlI/A I u w 1 1 I >al:nl vrla I