Laserfiche WebLink
ORIGINAL <br /> <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 />32-1 S. i,.a<,,o,v toot Cross Street <br />L. ,, L, 1 , 4, Assessors WELL Location .1-0,1iC C City (,)1-1X.--F—TVO Zip (157-Vi- Parcel# <br />PROP ERTYil . . j <br />Owner I (t( A-ra_mtok Address 5 in 1 E Neurs1A City %CHM Zip 752/5 Phone# 01 i L /6 /1- 4175 <br />C-57 Contractor Akaitfeel tied-KU Address 351 SlActi,o PA City 9Ni:6 Zip 95x.ic# 081iaPhone# (ze4)1-1.64, <br />Consultant / Sub Cntr Ali 4 KM' ti ec 64v Address g31 5tto-ii., Pd City sheihp Licit (.0 80227 Phone* OM V6 7 - MD <br /> <br />GIS Coordinates: X , Y Township <br />WORK TO BE PERF9RME• <br /> <br />XNEW WELL / RING ?CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />)(SOIL BORING # L a OVER-BORE. DIAMETER <br /> <br />1] WELL # 0 PRESSURE GROUT <br /> <br />a *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />['MONITORING <br />El HOLLOW STEM DIA. OF BOREHOLE 01 fl MULTIPLE CASINGS l] MULTI-LEVEL WELL CASING DIA: <br />fl EXTRACTION <br />0 VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL tidi fe. TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br />O AIR HAMMER/DRIVEN CASING THICKNESS V <br />TYPE OF CASING: a STEEL I] PVC ['OTHER: <br />V!USH POINT (GP or CPT)GROUT SEAL PUMPED: g Yes XNo . (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') jJ AIR SPARGE/ OZONE <br />)‘SOIL BORING <br /> <br />Fr) c 4--i..avtel a <br /> <br />, [I HAND AUGER GROUT SPECIFICATIONS <br />O OTHER APPROX. BORING DEPTH 4-160 BOLTED TRAFFIC BOX or 0 STOVE PIPE 0 OTHER: <br />CONDUCTOR CASING PROPOSED 91,./0 (if YES, list specifications in comment section) <br />COMMENTS: <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />; <br />Signed x , Title/Company LI € 0111 VA KC e A (ie CIAV ircn WestirtA <br />Print Name C-ireAt L. k SIAf4 Date Zti -DI4 <br />DEPARTMENT USE ONLY <br />Z407° SITE MAP IN UNIT IV FILE, ADDRESS: 82/ S. le/chok _ <br />WORK PLAN DATED: 7J8' 02_ <br />Range Section <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS. <br />Date Issued 2 —/2 —0 Area 0 <br />ate (.0 $0 • Date Final Inspection B Tul_r147.01 <br />Date <br />ACCOUNTING ONLY: AID* FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE P INVOICE <br />303 1 2—)' _4 1',# 603?;1- c•,t, <br />C-57 WC V -WAIVER ncroac 9/30/02 C-57 Letter of Authorization to sign permit