Laserfiche WebLink
WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date Issued / / 7/43 <br />Date <br />Date <br />Final Inspection By ( 44,te-e-c--- 1 Date <br />WELLOERMIT APPLICATION Fl iM <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 At, NEC EY!' LEIL <br />JAN 15 2003 <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 applicatiorENV141arittgAblAriEEAtilti-iSan <br />Joaquin County Development Title, Chapter 9-1115.3a nd the Standards of San Joaquin County Environmental Health Departmg-mt. FENATARVICES <br />WELL Location 5-1-(66 sed-tvi 4-, Cross StreetOed4"4 c:IL- City 5-110ceAyt Zipq-s 2CS Parcel# — <br />PROPERTY Owner /..le )0-- 77:41,—i-D Address,7771 E /r<1-‘?-lieel-Ca1leity Ad(474. 4e--e-4.._Zi(V-t. Phone#W2 T ( <br />C-57 Contractor WAS-f—Hil-2- 0414— Address.323FitLZVerce (89___ CitySA--(....- Zi(357<laiczei74nonetgaAbe 1,2Z <br />Consultant / Sub Cntr /4 , 03--C• Address 83-7 SIA-614----) gis---- City 1.1X-44-itic# Phone# 02d9" * <br />GIS Coordinates: X , Y , Township Range Section <br />Ar6-E—STRUCTION (choose type below) <br />AroVER-BORE <br />PRESSURE GROUT <br />'Other: Grout Specifications: <br />COMMENTS <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />fl SOIL BORING # <br />0 WELL # <br />TYPE OF WELL INSTALLATION TYPE <br />MONITORING )141OLLOW STEM <br />d2XTRACTI0N 0 AIR HAMMER/DRIVEN <br />g VAPOR El MUD ROTARY <br />AIR SPARGE / Ozone El PUSH POINT <br />SOIL BORING 0 HAND AUGER <br />] OTHER: 11 OTHER <br />'COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE R ‘,1.JLTIPLE CASINGS? 0 MULTI-LEVEL? G WELL CASING CIA: •-.1v1ci <br />CASING THICKNESS -- TYPE OF CASING: El STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL 1 5 rr--Cr--tl-- TREMIE TYPE TO BE USED: XAUGERS 0 HOSE <br />GROUT SEAL PUMPED: p,Yes 0 No (NOTE: MAXIM M FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH 4D r-f:ET- 0 BOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specTications here): <br />U3 .0-IL UN ( ArJe C )ll <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 Ordinance , Rules and Regulations, and all applicable California State Laws. <br />Title/Company zs-f . Signed x KNAChk.) I <br />'rint Name W7ft. /../14/6_, Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: cs <br />COMMENTS / CONDITIONS <br />. <br />ACCOUNTING ONLY: AID# <br />, <br />N <br />L.177 CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE PERMIT! SERVICE REQUEST # <br />, 3 56)- 62 0 Cooa2 1 --7oL( 30q ,./Y, <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />8/29/02 <br />