Laserfiche WebLink
JAN 2 4 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />RVIGI <br />. �11` <br />SITE <br />MITIGATION <br />UNIT IV <br />ENVIRl1NIMENT tiEALll t,4Li 4106-.s44tf rV <br />PERMIT/SERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 />Joaqu,n County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />WELL Location 1876 COlA1tY�_ciub EL,,d. Cross Street PbSSlorl____._._CityStoCktC%i --Zip_____ __Parcel# iA'knolAn <br />PROPERTY Owner i+. & AC'S. 1N_ nU21-SC_1C1]e7Address 1633 W.—Walnut City SCOC.[C P Zip95203_Phone#_2_09 464-1291 <br />C-57 Cortractor V -W LY \ <br />� 11 irk _ Address P.O. _fix 51 at�Zio Vista Zip_ 94571 uc# 720904 Pnone# 707 374-2815 <br />Consultant / Sub ContractorWeStem Geo --Ht 9Meer S Address 1386 E. Beamer St City WOOdLa-d,Lic# 5137 Phone# 530 668-5300 <br />GIS Coordinates: X <br />Township_ 1N Range -6E Sectio <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CFT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />p SOIL BORING OVER -BORE c� <br />SMELL #R-1 0 PRESSURE GROUT <br />'Other:_ Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING <br />[tHOLLOW STEM <br />0 EXTRACTION <br />17 AIR HAMMERIDRIVEN <br />I] VAPOR <br />0 MUD ROTARY <br />[j AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />[] HAND AUGER <br />BOTHER: Water <br />0 <br />r'ecover'y <br />'COMMENT <br />DIA. OF BOREHOLE 101' MULTIPLE CASINGS? 0 YES fl NO WELL CASING DIA:41y <br />CASING THICKNESS -"ch 40 — TYPE OF CASING: 0 STEEL $ PVC 0 OTHER: <br />DEPTH OF GROUT SEAL_ T TREMIE TYPE TO BE USED: r] AUGERS gHOSE <br />GROUT SEAL PUMPED: 0 Yes 13 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS:_ neat cmmt With <5%_be1tOTLlte <br />APPROX. BORING DEPTH_ Dr 11BOLTED TRAFrIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? no _ (;f YES, list specifications here): _ + <br />NOTJ: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 Ordinan Rules a_pdRegulations, and all applicable California State Laws, <br />Signed X_ _ _ _Title/Company Westem Geo-aE nea <br />Print Name G ' L. Converse Date - 2 3 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: (d T(O (.-o <br />WORK PLAN DATED: - / /0-(" -O 1 . �?diy2va� tC <br />Application Accepted By <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS / CONDITION <br />to <br />Date <br />Date Issued <br />Final Inspection By <br />!/1 <br />ACCOUNTING ONLY: <br />AID <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE <br />P T ! SE VIC # <br />INVOICE <br />C-57_ WC= WAIVERC-57 Letter of Authorization to sign permi Encroechment doc 9/27/00 <br />=ii C: _6007-t H1.�I= r Cr;= l +r�,;�1. F,S:CIT it12 r,; tl,i: C,T <br />