Laserfiche WebLink
WELLtERMIT APPLICATION FIRM <br />Range <br />Consultant I Sub Contractor <br />Application is hereby made to <br />Joaquin County Development <br />WELL Location 3-1-15- <br />PROPERTY Owner <br />C-57 Contractor C-ig-f*16°V;;;-(S Address City <br />SE CC) Ve-. <br />/ 491" <br />GIS Coordinates: X Township <br />SITE <br />MITIGATION <br />UNIT IV <br />ORICINAL <br />Lic# hone# -Tar Ify3 <br />Phone# tkraot-V-ICV <br />Section <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 />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />Cross Street \/3 . X...t‘r•r,\e‘ City Zip QVS-1 Parcel# Z12.- lib <br />rruj <br /> -28 <br />eoctotArc.41Adciress UOI:At C2.'4.\,9A VI City Zip 'S'S Phone# (\7 f2 ° Tiztlz=z (67k) 2..?/- <br />Address SO V1 V.A$50-1e W IL la.) City i4.4v1\o Ceak_ic# 663M? <br />WORK TO BE PERFORMED: <br />E] NEW WELL / BORING ( CPT. GEOPROBE, HYDROP,UNCH, HAND-AUGER, OTHER*) <br />*OIL BORING # <br />Li WELL # <br />'Other: Grout Specifications: <br />COMMENTS: Occ-sNe_ S oa t <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />fl MONITORING U HOLLOW STEM <br /> <br />D EXTRACTION El AIR HAMMER/DRIVEN <br />VAPOR [1 MUD ROTARY <br /> <br />I] AIR SPARGE U PUSH POINT <br /> <br />A <br />OIL BORING 0 HAND AUGER <br />OTHER: *THER bottir 't/4-1s\"\, a <br />*COMMENTS: <br />.‘ -Taal <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE •"-N" MULTIPLE CASINGS? (I YES Ai0 WELL CASING DIA: 1.../Ari <br />CASING THICKNESS 1•3/ilt TYPE OF CASING: El STEEL U PVC fl OTHER: <br />DEPTH OF GROUT SEAL 1'3 /Ac TREMIE TYPE TO BE USED: igkGERS fl HOSE <br />GROUT SEAL PUMPED:AfTs fl No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />4...t\- <br />c <br />GROUT SPECIFICATIONS: 1.. <br />APPROX. BORING DEPTH 30' BOLTED TRAFFIC BOX or fl STOVE PIPE <br />CONDUCTOR CASING PROPOSED? AO ( if YES, list specifications here): <br />_n <br />DESTRUCTION (choose type below) <br />OVER-BORE <br />°PRESSURE GROUT \S, <br />ITN 1)2- OGCOL o-v‘c) <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 />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />SECCV- `/A-PSC:eii <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: ,925-5- <br />WORK PLAN DATED: \JUL., c cf) <br />Application Accepted By Date Issued <br /> 471 Area <br />Grout Inspection By 4./ Date <br />Destruction Inspection By Date <br />COMMENTS /CONDITIONS. <br />ACCOUNTING ONLY: AIDS FACJt 61—R 9049-6-4,S <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS REVD BY DATE ERMIT / SERVICE RECIU INVOICE <br />, 35--. ( 8 7 A C (7 6-65-: Or (2'/7A.2- SR# <br />Signed x <br />Print Name N.. Date kOIS-10 X <br />Title/Company <br />Final Inspection By Date <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign perrnitj ., Encroachment doc <br /> <br />9/27/00 <br /> <br />£0 39Vd aomi CEVE89V6OZ IE:EI 000Z/P0/ZI