Laserfiche WebLink
<br />ORIGINAL <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <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 Joaquin County <br />Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />e4(iFic. Iv Assessors <br />WELL Location Li LiC PACteIt- Atotnvt, Cross Street t mus ; ST, City s 7-04- K Tors Zip95 2 fa Parcel# )) •Aya- 14 <br />‘i) qo <br />PROPERTY Owner E C rt", Tr 6 Address „.7 6 rik;F,., ../tk, City S roc K rot.) Zip Phone#(2 .) I/78 - 554 C3 k".) <br />wtyrtr rJ ski;:,57 , <br />C-57 Contractor Al" vplc,fteti onAddress P.0. Sh City 54./..,,Kwit Lic#561.141hone# ti 10 37 5-// <br />Consultant/Sub Contractor A G., E. Address 8 3 7 6,44.,1 RD. city Slit frron Llc#6b-7 Phone#2 °`‘.) çi 1-/ no ‘0 <br />GIS Coordinates: X , Township it? r‘if Range Section <br />WORK TO BE PERFORMED: -C VEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER-BORE 0 <br />„IK # trialOG V w - 3 , U\ *Other: <br />NELL <br />Grout Specifications: 1'1-71D T ye E Tr--- <br />0 PRESSURE GROUT <br />COMMENTS: SE- el APPR4() kivt,rk P16.) Como 15 8Rviii -) 2 co 2.— •-•::::, <br />Z <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Q. <br />0 MONITORING XHOLLOW STEM DIA. OF BOREHOLE IF, 0 MULTIPLE CASINGS? 0 YES )cNO WELL CASING DIA: 9 <br /> <br />_9.4 c-.),40-. rs <br /> <br />y 0 TYPE OF CASING: 0 STEEL )21,PVC a OTHER: 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESb- <br />a OTHER: fl OTHER APPROX. BORING DEPTH S r) FT 6,5(/. BOLTED TRAFFIC BOX or I] STOVE PIPE <br />CONDUCTOR CASING PROPOSED? N ,.. (if YES, list specifications here): <br />GROUT SPECIFICATIONS: Pot' TIC* 0 a "Ty pc 1r ..*-) <br />VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL G Fr 85(; TREMIE TYPE TO BE USED: AUGERS U HOSE <br />0 AIR SPARGE B PUSH POINT GROUT SEAL PUMPED: 0 Yes XNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER <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 County Ordinances, <br />Rules and Regulations, and all applicable California State Laws. <br />Signed x <br /> it't Print Name -77,1,1 r, rf4 J. _ <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: Z <br />Title/Company PRCISECT G.--:t./t51,--r-1A .6 • . <br />Date 0 5/ 74/ Co <br />DEPA TMENT USE ONLY <br />/I/ <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date <br />Date <br />Date Issued 2.- Area <br />Final Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE EMIT / scovir RFOl ES INVOICE <br />2601 Mrla Z qet 16,Flto adt ?::. i sR#a3,004/i <br />-WAIVER C-57 Letter of Authorization to sign permitZEneQchment doc <br /> <br />1/25/02 <br />