Laserfiche WebLink
*r,gVED <br />FEB 0 A 200 <br />EP�V�i3ONMSERVICES 11 <br />� `�f11T1 <br />pf�S <br />WELL PERMIT APPLICATION FUR SITE <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />MITIGATION <br />UNIT IV <br />4 t 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 />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessor's <br />WELL LocationZ749Z SOLXVA AAr�_�Cross Street O — City Zip rJZO Parcel# I&J-06-55 <br />LA LT"" 4 Z,&OA / q /' <br />PROPERTY Ow efj�S,��Ft-uJ1�}�EQ� �,�{� t Address/i�(7 IVCa�IL� Cit y Zip*��3Phone X41'01 <br />C-57Contract'or't�k'a'1 bfiki,I���YV)%Wggss �R�o iiijly�l � A City�Aftt�-A Zip955b3Lic#L�2601 Phone 16 444-%q0 <br />Consultant/ Sub Cn�ye:za &4\tt 20k*rci TALAddress `'I'170 Akd t 1 City 1 l gii# Phone# 910 9 / l- 217c <br />GIS Coordinates: <br />Township <br />WORK TO BE PERFORMED: <br />-ON EW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") <br />0 SOIL BORING # <br />ELL # <br />'Other: 24"ef- A1oLi4 Ill-I,�IV-�� l yhw�fAt %l1 ^I Grout Specificat <br />COMMENTS <br />TYPE OF WELL <br />INSTALLATION TYPE <br />'MONITORING <br />gHOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />VAPOR <br />0 MUD ROTARY <br />%AIR SPARGE / Ozone <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER: <br />0 OTHER <br />Range <br />Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS 0 <br />DIA. OF BOREHOLE MULTIPLE CASING �0 ULTI-LEVEL? 0 WELL CASING DIA: Zp <br />CASING THICKNESS Q TYPE OF CASING: 0 STEEL )ZPVC 0 OTHER: <br />DEPTH OF GROUT SEAL1ct d4up t" TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes �grNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 301 <br />GROUT SPECIFICATIONS: l� L1M� ttc <br />APPROX. BORING DEPTH,1oc Q*rc1,2dd XBOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? t4y ( if YES, list specifications here): <br />`COMMENTS: w fJetA GoAA=Ez� ch t-�*ac/ty►e� <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 />hereby certi <br />County Ordin <br />Signed x <br />Print Na <br />V' <br />hat I have prepared this application and that the work will be done in accordance with San Joaquin <br />:es, Rules and Regulations, and all applicable California State Laws. <br />r <br />Tit lesIC' mmnnnv fvb�iCl.tT(:;r <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />Date <br />Date Issued <br />Final Inspection By <br />ate 3 <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED CHECK/# <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />C-57__ WC= WAIVER_ C-57 Letter of Authorization to sign permit ent. oc 8/29/02 <br />