Laserfiche WebLink
SAN JOAQUIN COUNTY ORIG! t 11 ! TE <br />(� (� �� %C,N <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />V �ll V 6411 st Weber Avenue, 3 Floor, Stockton, CA 95202-2708 <br />(209) 468-3449 - Fax: (209) 468-3433- Web: www.co.san-joaquin.ca.us/ehd <br />IN 1 7 2004 <br />MITIGATION <br />UNIT IV <br />ENVIRONMENT HEALTH WELL PERMIT APPLICATION FORM df�-f 0 Pu) <br />PERMIT/SERVICERON-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 />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />WELL Location 1910 CCLntr'y QLlb BlVd. Cross Street MLSSion City StOCkton Zip 9520� Parcel# U'll4jan <br />PROPERTY Owner Sari JCRQPI�ty Address 1810 E_ IEeltcn City. StOCktcn Zip 9520*5 Phoney 6&-305 <br />C-57 Contractor Yd Dri l l irg Address P-0- Box 336 City 0 VistaZip 94571 Lic# 710079 Phone# 707 374--4300 <br />Consultant/ Sub Cntr ir�tern Geo—I 1g1t7efx5Address1'�86 E_ Wit^ St City tnbcxllanr3 Lic# 513 7 Phone# 530 669 <br />GIS Coordinates: X Y Township 1N Range 6E Section 4 <br />WORK TO BE PERFORMED: <br />EW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />0 SOIL BORING # <br />$WELL # W9A R3 <br />0*Other: <br />COMMENTS: <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE — DIAMETER_ <br />0 PRESSURE GROUT <br />Grout Specifications: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[MONITORING 9�1-10LLOW STEM DIA. OF BOREHOLE 8" MULTIPLE CASINGS? 0 YES tNO WELL CASING DIA: 2",j <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 1,h X40 TYPE OF CASING 0 STEEL )(PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 10.5' TREMIE TYPE TO BE USED: 0 AUGERS10SE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Neal- C:a mt With 5% bmtcn i.te <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 18 Pf BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />*COM <br />CONDUCTOR CASING PROPOSED? no ( if YES, list specifications here <br />NOTE: 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 Ordinances,,Rplep apd�Regulations, and all applicable California State Laws. <br />Signed <br />Print Na <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: � <br />Application Accepted By <br />Grout Inspection By_ <br />Destruction Inspection <br />COMMENTS / CONDITIONS: <br />Title/Company Project GeolaTist. kleStem Geomagia m <br />Date <br />DEPARTMENT USE ONLY <br />7F Z�l lkvl I -W <br />—U J <br />Date Issued (0 �'� Area <br />Date Final Inspection By w , 6r to <br />Date <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PE SERVICE REQ INVOICE <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit nc ent do <br />60.E -17Z« <br />EHD 29-02-001 WELL PERMIT SITE <br />8/27/2003 <br />