Laserfiche WebLink
UMINAL <br />IA Cat <br />Crtla 17-g 7-124 <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 />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 <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />FOY t 64 /4/ ' <br />i , ,• zip 95 2 03 PAasrcseelsttsoiEscis _ 0 30.0 i <br />WELL Location Cross Street - • C. _.ty a eatcrn <br />p l-‘, PROPERTY Owner Pert of .to441--0 n Address .0.&01 2031 City -t0f-ttbil Zipt1520 1 Phone# ,. 2 o141424b <br />C-57 Contractor \Jiro no( , 1 vte Address Quo A -et coil s Ali - i,11-0,‘ nitro zipc145 1 <br />hgeb-errtr6 424VVIANX 6-itilevitAddress <br />3 ILIC#16127 Phone#5i0 -58-1676 <br />Consultant i444 PA Ai A St., Ste. 2c1t5y Fre> 0 0 uot tg 38-65 phone#559 -264- 2535 <br />GIS Coordinates: X , Y , Township 1 <br /> <br />Range 1; E Section <br /> <br />WORK TO BE PERFORMED: <br />)(NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) ‘0 DESTRUCTION (choose type below) <br />4/8/SOIL BORING # 2 (rut; d )cia ireet rid ay a OVER-BORE <br />ELL # +o fl PRESSyRE GROUT <br />*Other: Grout Specifications: 1142.9-t- Ce44411.1 9 awl- iftWi itr <br />COMMENTS <br />E <br />DEPARTMENT USE ONLY <br />Date <br />DEPTH OF GROUT SEAL <br />GROUT SEAL PUMPED: n Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: VI tat-- ami iti4 t <br />APPROX. BORING DEPTH fYlovx 50 ' BOL ED TRAFFIC BOX or STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />TYPE OF WELL INSTALLATION TYPE <br />Oil WIG -ORINTT--------------)/HOLLOW STEM - <br />0 -EXTRACTION AIR HAMMER/DRIVEN <br />[]VAPOR 0 MUD ROTARY <br />0 AIR SPARG y(PUSH POINT:•;4P <br />%son_ BORING _, 0 HAND AUGER <br />0 0 HER: 0 OTHER <br />CONSTRUCTION SPECIFICATIONS ey // <br />DIA. OF BOREHOLE 1 01/ MULTIPLE CASINGS? YES /NO WELL CASING DIA: L. <br />CASING THICKNESS TYPE OF CASING: fl STEEL ji/PVC fl OTHER: <br />TREMIE TYPE TO BE USED: fl AUGERS 0 HOSE <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 Ordinances, Rules d gulations, and all applicable California State Laws. <br />Signed x Title/Company N.1 V1 2-12-4/64,,e yvl a to y <br />II/2210Z <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br /> <br />ocr zav.' <br />Date Issued_t Area e 6 SY Application Accepted By <br />Grout Inspection By Date Final Inspection B, Date /— 2-3 -03 <br />Destruction Inspection By <br />COMMENTS (CONDITIONS: <br />Date <br />ACCOUNTING ONLY: AID# FAn# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVI ES1# INVOICE <br />36°L 4e7 /c 73 0 aalk- a ' z — S R# te .,;. /I r <br />C-57 V WC -WAIVER C-57 Letter of Authorization to sign permit ent d c 1/25/02