Laserfiche WebLink
SITE <br />MITGATION <br />UM. N <br />ORIGI <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING a HOLLOW STEM <br />0 EXTRACTION a AIR HAMMER/DRIVEN <br />U VAPOR 13 MUD ROTARY <br />- 0 AIR SPARGE PUSH POINT <br />1CSOIL BORING U HAND AUGER <br />13 OTHER: a OTHER <br />Bor A Lho, '•COMMENTS: <br />DEPTH OF OF GROUT SEAL /00 Pr TREMIE TYPE TO BE USED: U AUGERS a HOSE S <br />GROUT SEAL PUMPED: jiYes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: PC c--irAi.k.14 <br />APPROX. BORING DEPTH 1(X) F.- V 0 BOLTED TRAFFIC BOX or STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />0 40 ‘‘C " Tedrot 103 <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2 In MULTIPLE CASINGS? fl YES a NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC a OTHER: <br />zs, <br />Loli=5 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUELJC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISiON (PHS-EHD) <br />304 E. Weber, Third fioor, Stockton, CA., 95202 <br />(209) 463-3443 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereoy 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 />WELL Location 1005 ?a c ;c,c.. kve_ Cross Street P>anC IA g City S40(ikkiel Zip 95 2O '7 Parcei# <br />Assessor's <br />PROPERTY Owner 3eri-y C -u 4-- .. . 0 Address 99os" Ric, Ck_ Aut.. City S 40(4i74 Zip 75-010 7 Phone# <br />C-57 Contractor Greh TA S: h.) Address .5-6 ) /4614Je_ R tO City Ma 14 irl-eKZip 9*513 Lic#(057/997 Phone# ?.25-- 3 13 -s-861...) <br />Consultant / Sub ContractorkLtrocklev Criti.rornMmici Address Cs/3 7 si,,,k..) Rk City Siock-kii Lic#140,22 -7 Phone# 4/60 7-/97 <br />Section <br />WORK TO BE PERFORMED: <br />a NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCHg-lAtsE)-AlGER, OTHER') <br />tESOIL BORING # 9 C — r "/ <br />n WELL # <br />*Other: Grout Specifications: <br />COMMENTS: <br />DESTRUCTION (choose type below) <br />U OVER-BORE <br />0 PRESSURE GROUT <br /> <br />GS Coordinates: X , Y Township Range <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 Or,ina ces, Rules and Regulations, and all applicable California State Laws. <br />Signed x 74 <br />Date 0 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 2 5 <br />Title/ComPanY 6/0 faeOlf•-i•Id Cetki, .1—/4iwiroA Geo enu,rol ( <br />Print Name Cipti-S:717Vhe.r- a iviii1/„. <br />Application Accepted By Date Issued <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />Ze Date <br />ACCOUNTING ONLY: AID# FM-4 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE r SERViut KECNI <br />0/ .515 /67 .(c) /4/--- 6 — / 1.§::.1.# 00 2-4 74":5 <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign pertni nc • <br />