Laserfiche WebLink
SITE <br />MITIGATION <br />UNIT IV <br />Date Issued Application AcceptedAccepted By <br />Grout Inspection By <br />Destruction Inspection By <br />/ ‘6Pci <br />40 1,141 FPV <br />/411r7 Date Final Inspection By <br />Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: sc12..5 <br />WORK PLAN DATED: <br />4zeo, <br />ORIGINAL <br />WELL PERMIT APPLICATION FORM <br />WCIEIROT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />SEP 20 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />ENVIRONIVIEN1 AL1 <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />HE <br />PERMIT/SERVICES <br />(209) 468-3449 <br />NON-kERINDABLE 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 />WELL Location -•406 4-t. 4 t, eetc. Cross Street Ar-4740-Rd City Zip 75.2°7 Parcet# RI 2E43 2,‘ <br />PROPERTY Owner c/r/wicriit 711647100-5 Address/6a' aieceirr ./Cr4/..9-tity 4.14:?eril Zip qi112 Phone# 05-/a lvt, Fir <br />C-57 Contractor (1./ocCit4aki PA.,1111 Address PO. a( 3,26. ctrye.6.,y zip9i1S-7/ Lk* NW'? Phone# X7 3 7i4 <br />Consultant / Sub Gontractor Uif.510'07 (06,- fy. Address ) 3,6 gempfrs4.city tchz4A4.6c# .573857 Phone# CC, Siot, <br />Section 2/ <br />IIDESTRUCTION (choose type below) <br />OVER-BORE <br />ErPRESSURE GROUT <br />Grout Specifications: 3 kecir Auk new( c.-/ 5- % 0.4 .4.1, <br />COMMENTS: <br />GIS Coordinates: X , r , Township .2 A/ Range 6" <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />1:1 SOIL BORING # <br />0 WELL # trte, <br />*Other: <br />NL, <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING 0 HOLLOW STEM <br />B EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE 0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />0 OTHER: a OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA OF BOREHOLE MULTIPLE CASINGS? 13 YES 0 NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS HOSE <br />GROUT SEAL PUMPED: Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />BOLTED TRAFFIC BOX or 0 STOVE PIPE <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 s, Rules and Regulations, and all applicable California State Laws. <br />Title/Company t/ • Signed x <br />Print Name 6'ec-07e Z e.4,1c Date 9-i'? <br />DEPARTMENT USE ONLY <br />— •-• - • - • --•-- Li _ - <br />e_-)- -1\7 COI 17 Or-.? .7.7) ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />3502_ _ itgb (at/ 5113- 2 '-*X1 SR# 00 i 21- <br />r wr -Vt/ AT \/FD r I ottor rtf A,Itknri7,t1 +ri cinn normit ' rirrnrir mon nr