Laserfiche WebLink
ur WELL PERMIT APPLICATION FORM <br />SEP 2 7 200SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />ENVIRONW.i 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />ORIGINAL <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 />WELL Location kS OS- S CA -KRA Cross Street - 4,3r. City (JA'Aevt) 0 Zip ci,S33 0 Parcel# <br />PROPERTY Owner lionetic-, ,...o.v );\ov. Address ?.Q. City LAMA wp Zipc4c3)0 Phone# <br />, SU-4,11t lt ck <br />C-57 ContractorS1,040,0 Address --)A e.H4tVeAL0" Lic#(0i0227 Phone# 0 -11W - y yji <br />Consultant / Sub Contractor 7kft.,L City CAtitiLL, Lic#C,S022.71 Phone#Z-0?—ki (0 7 - look <br />GIS Coordinates: X , Y , Township Range Section <br />0 DESTRUCTION (choose type below) <br />fi OVER-BORE <br />a PRESSURE GROUT \C\ <br />\P <br />WORK TO BE PERFORMED: <br />tt(NEW WELL / BORING ( CP <br />*Other: <br />COMMENTS: <br />, HYDROPUNCH, HAND-AUGER, OTHER") <br />a SOIL BORING # <br />a WELL # fits e 9, <br />Grout Specifications: <br />TYPE OF WELL INSTALLATION TYPE <br />o MONITORING a HOLLOW STEM <br />O EXTRACTION AIR HAMMER/DRIVEN <br />VAPOR a MUD ROTARY <br />O AIR SPARGE IK.PUSH POINT <br />&SOIL BORING a HAND AUGER <br />fl OTHER: a OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2,1' MULTIPLE CASINGS? flYES .NO WELL CASING DIA: AJA <br />CASING THICKNESS AJA- TYPE OF CASING: a STEEL a PVC a OTHER: <br />DEPTH OF GROUT SEAL TrAtti 1.1m0(14,, TREMIE TYPE TO BE USED: a AUGERS -WHOSE <br />GROUT SEAL PUMPED: 41Yes r (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: 0-A,LIAA 3 15_ <br />APPROX. BORING DEPTH a BAD TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? Po ( if YES, list specifications here): <br />cr GI( CU k-Af Ct_ <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 Ordi nces, les and Regulations, and all applicable California State Laws. (t <br />iktiz--cir c zti). (yi-- /Akoc(,,,ok Geo kole Title/Company <br />DEPARTMENT USE ONLY <br /> <br />Signed x <br />Print Name Q,9,\A) Date 5 24 <br />SITE MAP IN UNIT IV FILE, ADDRESS: 6'6/5 S. 7N4 54 — <br />WORK PLAN DATED: <br /> <br />'41 <br />2400 / <br /> <br />Application Accepted By Date Issued <br />Grout Inspection By <br /> Date Final Inspection <br />Destruction Inspection By <br /> Date <br />Area o6E-4 <br />Date 7. 2.G • 0 2-• <br />LAJIIIIIVIGIN I J I ,...urivi I nave., <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # RE 'D BY DATE P 1 -, = f, ST # INVOICE <br />So t 4 : <br />..... e".- • Alt I" ..1....it -1: 00 2. 24 <br />• 0 1.97 inn <br />C-57 WC -WAIVER C-57 Letter of Aut orizat on to sign permi