Laserfiche WebLink
I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordi ances ules and Regul tions, and all applicable California State Laws. <br />1/41 tki\-A)1A vATitle/Company (led 31-- (cuattyvicat, cry ‘) Slgned x <br />DEPARTMENT USE ONLY <br />Date 0 0 <br /> <br />Print Name <br />WELL PERMIT APPLICATION ARM <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 /> <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />NONREFUNDABLE 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 Public Health Services. Environmental Health Division. <br />I br; -, Assessor's <br />WELL Location ".3 CO C Navio- Di V-C-' Cross Street_o h ..,.. KAL1S+14412 City t--.0../C7Vil Zip C1S—g6 Parcel# 1 LA - 030 -1-1 .4 A ut #C-75- ..i)e. M alki vti vI S <br />PROPERTY Owner Oi(4- Tet41/11vtici Ad drest) I Y P-(7) fILY.Yr)14irot City allic Zilp.415-24/7 .'hone# etta c 3 D 6S X <br />Address /414,), Edife-L4- - Cltyj^1221kLic# Phone# Li ST-) Consultant / Sub Contractor ra ii11171iift elt <br />GIS Coordinates: X , Y Township Range Section <br />C-57 Contractor \) \'A V1;0\ Cf\-3 Address ca) EC)\/( S-1 City Vi 0 k)Otil. ZipT/5-7/ Lic110/041 Phone#9/6 -:7 --ti/ <br />WORK TO BE PERFORMED: <br />*NEW WELL/BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br />SOIL BORING # CPI .Threnk c.,43 <br />a WELL # <br />DESTRUCTION (choose type below) <br />0 OVER-BORE <br />0 PRESSURE GROUT <br /> Grout SpecJfIcatIons: <br />e).-1AvL-8,S 5.; -if fx/i — <br />CONSTRUCTION SPECIFICATIONS <br />DIA, OF BOREHOLE 7,11 MULTIPLE CASINGS? fi YES ANO WELL CASING DIA: <br />CASING THICKNESS t ,ick- TYPE OF CASING: 0 STEEL fl PVC fl OTHER: <br />DEPTH OF GROUT SEAL jt TREMIE TYPE TO BE USED: 0 AUGERS )(HOSE <br />GROUT SEAL PUMPED: a Yes ii.No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH 1.S.- 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED'? ityl )\ ( if YES, list specifications here): <br />*Other: <br />COMMENTS:IC •fr J <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING 0 HOLLOW STEM <br />1:1 EXTRACTION 0 AIR HAMMER/DRIVEN <br />p VAPOR 0 MUD ROTARY <br />0.AIR SPARGE 0 PUSH POINT <br />SOIL BORING 0 HAND AUGER <br />fi OTHER: 71,0THERODOIOdy4' <br />*COMMENTS: <br />ca adce tre--iivo 1`--F • <br />bes <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 />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Date Issued /0/SO/O0 <br />Date 2- ad Final Inspection By <br />Date <br />COMMENTS / CONDrTIONS- fc( <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />leAA <br />Area CL),--12c-t3 <br />Date <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE PERMIT /SERVICE R • • n...T# <br />591 ar -- /54 °6 (72 14 X.- I A 1 i ) SR# OC(9-4Picg <br />C-57 WC <br /> <br />-WA IVER <br /> <br />C-57 Letter of Authorization to sign pe mit oc <br /> <br />9/27/00 <br /> <br />EEt7E89176K St':OT 000Z/8T/OT 7,0 39Vd