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SR0023406
EnvironmentalHealth
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2900 - Site Mitigation Program
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SR0023406
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Entry Properties
Last modified
5/8/2023 11:52:10 AM
Creation date
4/24/2023 2:01:51 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
RECORD_ID
SR0023406
PE
3501
FACILITY_NAME
offsite for RANCH MARKET
STREET_NUMBER
23665
Direction
S
STREET_NAME
SANTA FE
STREET_TYPE
RD
City
RIVERBANK
Zip
95367
APN
249-070-009
ENTERED_DATE
7/14/2000 12:00:00 AM
SITE_LOCATION
23665 S SANTA FE RD
P_LOCATION
99
P_DISTRICT
005
QC Status
Approved
Scanner
SJGOV\bmascaro
Tags
EHD - Public
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E4/28/2000 08: 23 <br />2094603433 FIFTH FLOOR <br />PAGE 03 <br />ORIGINAL <br />WELL PERMIT APPLICATION FORM UNIT IV 6) <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct ancUor install the work described. This application is matte in compliance with <br />San Joaquin County Development Title, Chapter 9-1115,3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />C-57 Contractor i,:t0,1.-kA-2 kvi,‘Av Address 3i3i FitzAca.4;(201 413 <br />Consultant / Sub Contractor '-/-T-ut( Addre.ss5N7 kx"City LIC#it) 2- Pnone#V‘• X44 /0) <br />GIS Coordinates: X Y Township 3 `-it-i.A-le‘ Range q section 2•9 <br />WORK TO BE PERFORMED <br />0.,NEVV WELL I BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />1:1 SOIL BORING # <br />_WINE L L # <br />a DESTRUCTION (choose type below) <br />OVER-BORE <br />0 PRESSURE GROUT <br />'Other: <br /> <br />COMMENTS: <br /> wol <br />TYPE OF WELL INSTALLATION TYPE <br />'MONITORING HOLLOW STEM <br />exTRACTICIN I] AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />El AIR SPARGE fl PUSH POINT <br />SOIL BORING 0 HAND AUGER <br />0 OTHER. fl OTHER <br />CONSTRUCTION SPECIFICATIONS <br />CIA. OF BOREHOLE 9" MULTIPLE CASINGS? 0 YES ArNIC WELL CASING DIA, <br />CASING THICKNESS 1-('-hf. i-1491 TYPE OF CASING; D STEEL ,ttEsVC fi OTHER: <br />DEPTH OF GROUT SEAL /6 TREMIE TYPE TO BE USED: ;0•AUGERS WdOSE <br />GROUT SEAL PUMPED; lit Yes n 90 (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH ,BOLTED TRAFFIC BOX or I] STOVE PIPE <br />CONDUCTOR CASING PROPOSED? /V0 (If YES, list specifications here) <br />COMMENTS: <br /> <br />LoCU =ID (,,t <br /> <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />and Regulations of the San Joaquin County. Homeowner Or licensed agent's signature certifies the following: -1 certify that in the performance of the work <br />contracting signature certifies the following: 1 certify that in the performance of the work for which this permit is issued. I shall employ per.s..,on ,subject to <br />I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances, State Laws, and Rules <br />for which this permit is issued, 1 shell not employ persons subject to WORKERS' COMPENSATION Laws of California" Contractor's hiring or sub- <br />WORKERS' COMPENSATION Laws of California" <br />CAL1 T4EUNIT Ft AV.WARKKGAIRS-1 N A DVAN_CE.P.0 RALli4REQU I RED ANSPE'O'Flp N`S, <br />GELOiL fey- A-2 .2 4-'414/ 4-7L. Title/Company Pr2rc4 Makiktycr <br />e..r AA-11-C <br />of:Fda_ <br />us till& <br />Assessor's <br />WELL Location 2 3 Q.A0S-5 cc.+k E R4L cross street City ktA k Zip 13-367 Parcel# -.010 -00i <br />PROPERTY Owner T&.( '-'91 Add ressz RA0C re, /2e. City kv'' k zip 15.3417 Phone# 2.°1 ia -2at.3 <br />City-4,0„4t, Zip K5-71/ Z_ Lic#5-5W79' Phone#94: - 7 2- 7(; <br />Signed x <br />Print Name cSifi <br />Area <br />DEPARTMENT USE ONLY <br />Date Issued <br />Date Final Inspection By Date <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By Date 0 0 COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: AID# FACV <br />\INVOICE --r <br />PE CODES FEE INFO AMOUNT REMITTED CHECK It REVD BY DATE P ... i : : QUEST ft <br />. 101 Z3 2_ C-1.4- -----. • sRit <br />inPinnn
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