Laserfiche WebLink
Signed x <br />Print Name 44A42 L s <br />Date Issued <br />Final Inspection B <br />Area 6e <br />Date <br />Date <br /> <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 />LIMT PS 2003 <br /> <br />ENVIRONMEN i HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FRMITAERVICF% Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in co p lance wi h an <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />WELL Location 113 4 6 1.4(.31 /..) Cross Street 44.4 E_ City (.0)> k Zip S— Z-'(D Parcel# b5 <br />PROPERTY <br />Owner -r.?-1- I A.,cfc,r_ic-, Address la% 14 6.1-1 qc, r-) City (.o>t Zip52'.(0 Phone# i ¶3 I 4, Cscrtl <br />C-57 Contractor G vac-7 G (J s r-ru Address q57) HoWE. oA3> City/11AV7P+22. Zip 14/553 Lic# '01 Phone#525, 5E-0 o <br />Consultant / Sub Cntr 13401.4 rs.1 114> Cht_AurtA.AAddress 270I 5PE.c1 2ic Cityi.8_0(Anstiz# <br />GIS Coordinates: X , Y <br />Phone# 574, piq y <br />Section 3 , Township Tri Range7 <br />WORK TO BE PERFORMED: <br />NEW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />El SOIL BORING # <br />g*Other Cer f.17 <br />0 WELL # <br />COMMENTS: <br />a DESTRUCTION (choose type below) <br />a OVER-BORE. DIAMETER <br />fl PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />a MONITORING a HOLLOW STEM DIA. OF BOREHOLE 1.i" a MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: <br />U EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS AtONJE- TYPE OF CASING: a STEEL 0 PVC 0 OTHER: <br />U VAPOR a MUD ROTARY DEPTH OF GROUT SEAL I 3 0 ' TREMIE TYPE TO BE USED: a AUGERS 13 HOSE <br />U AIR SPARGE/ <br />? <br /> OZONE PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 2 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />SOIL BORING I( <br />U OTHER: <br />a HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER APPROX. BORING DEPTH 13 O ' 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED N.1 Dr*..-.'. (if YES, list specifications in comment section) <br />COMMENTS: At..1— g ,. L. G 5 i.,/i 1-4- 3E...- Ai? ou—F-i> A-PrE2," Ca /4 ?LE- 77 z "4 OF C T-T" <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR 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 OrçIpances, Rules and Regulations, and all applicable California State Laws. <br />Title/Company 01St ,_•1/4i71s ga64,-4 44i> <br />Date 5 J i ( 0 3 <br />SITE MAP IN UNIT IV FILE, ADDRESS: il36 99.14;1:44-4143.1 440/° <br />WORK PLAN DATED: 3'1?-0, <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS! CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE QU T # INVOICE <br />aso 1 sED s? '- /u)47 Ck-- 541 SR# <br />C-57 Letter of Authorization to sign permit ..-€1.4c.anar_13,4‘fiate"- 9/30/02 <br />00971X— <br />C-57 WC %.7-WAIVER