Laserfiche WebLink
SITE <br />MITIGATION <br />UNIT IV <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? a YES 0 NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: a STEEL 0 PVC a OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br />GROUT SEAL PUMPED: a Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br /> APPROX BORING DEPTH <br />CONDUCTOR CASING PROPOSED? <br />a BOLTED TRAFFIC BOX or STOVE PIPE <br />( if YES, list specifications here): <br />TYPE OF WELL <br />fl MONITORING <br />o EXTRACTION <br />D VAPOR <br />a AIR SPARGE <br />O SOIL BORING <br />0 OTHER: <br />INSTALLATION TYPE <br />fl HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />O PUSH POINT <br />0 HAND AUGER <br />0 OTHER <br />Print Name i:ye r'one.cive <br /> <br />Date c/ <br /> <br />DEPARTMENT USE ONLY <br />4I5 adt L-Of <br /> <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br /> <br />WORK PLAN DATED: 0 / <br />662V <br />Date Issued <br />Final Inspection By <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date <br />Date <br />.t•.= 4-0/- 2514 <br />ORIGINAL <br />WELL PERMIT APPLICATION FORM <br />SEP 2 0 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) E ' ' <br />Ne‘rr— TO <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />'1030a- (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 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 />Assessor's <br />Cross Street x•rial 4/ City 5;6041=•1 Zip q5.2,6 7 Parcel# WELL Location ‘0093 <br />PROPERTY Owner 5'4,1 7ecredi ace#2I Address /.76 ar WO City.57644/cel Zip 47,72G/ Phone#.2eN' 4768.-300:7 <br />C-57 Contractor 1,6tvet14,34014ti-Ay-- Address g 6 . 06?‘ 3% Cityakfiet Zip 94.157/Lic# Woo 79 Phone# 707 ?7* giva <br />Consultant / Sub-Contraotoade5)601 6-4, - -ay., Address 1116 ;harir),46 5-74 Cityk422:171119eic;# SaffS7Phone# 53, ‘42?-473 <br />Township 24". <br />c7 <br />GIS Coordinates: X , Y Range 6. &- Section 2. 1 , <br />*Other: <br /> <br />COMMENTS: <br />*COMMENTS: <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 Ordina ces, Rules d Regulations, and all applicable California State Laws. <br />Signed x Trtie/C,ompany 6pelee4r-eiti ("6eYldwA ("7":"•-iy <br />WORK TO BE PERFORMED: <br />NEW WELL! BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') a SOIL BORING # <br />1,!A(ELL # med./7 <br />DESTRUCTION (choose type below) <br />0 OVER-BORE <br />VPRESSURE GROUT <br />Grout Specifications: 3 54^,x nay/ al 5' <br />ACCOUNTING ONLY: AID# FAG# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE p :Ps,. • 1 U • • <br />CAA. - -ge) sR# i 047-541 <br />'Air - V1/ A T VF <br /> r..A7 I o•h+or nf Au ithnri-yntinn <inn norut