Laserfiche WebLink
\,1 ic/for: 1-•• C- -4C1 e <br />Date 3 <br />Date <br />Application Accepted B <br />Grout Inspection By <br />Destruction Inspection By <br />Signed x <br />Print Name Siff/CAE (--#1A1(-1 <br />WELL PERMIT APPLICATION FIRM <br />EJI <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />MAR 2 2 2004 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />LALTI-1 <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />PERMIT/SERVICES (209) 468-3449 <br />°RIGINAL <br />AvirtAiVibu I f-I <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 Public Health Services, Environmental Health Division. <br />Assessor's <br />Parcel# j3 <br />SITE SITE <br />MITIGATION <br />UNIT IV <br />WELL Location 139 5ot4.-r-f1 Cedre-XSrieger Cross Street 1,1erstiogilbikl .Sr. City 5-115CATtin! Zip 952.02 <br />PROPERTY Owner CrYoF ,s72>cAronl Address 425 Ai. STaerCity SrociCilW Zip '15202 Phone# (204) (-137 im-39 <br />amx_mo <br />C-57 Contractor lA5UkDE- DietLun)(1 Address •3(s.,•4-• omecc-lei-Le City Cog.Po4A Zip95742 Lic# Phone#01(1) (&.3g <br />XAN„C40 <br />Consultant / Sub Contractor Satle iNTE kni-ttibiutti Address 3Or1 KAU-104e S‘ 411—c-160 City u)K-0044 Lic# Phone#(1(e) y6,1-646 <br />GIS Coordinates: X , Y ,Township Range Section <br />WORK TO BE PERFORMED: <br />U NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />SOIL BORING # <br />WELL # 5 (ii.Lu,)-,r,--41 <br />*Other: Grout Specifications: <br />COMMENTS: <br />DESTRUCTION (choose type below) <br />fi OVER-BORE <br />PRESSURE GROUT <br />ei.)-1-6,\)t if - rOg-I <br />Date Issued ma r6 2.9)2-00 Area <br />4-' <br />di 4 I. <br />TYPE OF WELL INSTALLATION TYPE <br />g MONITORING II HOLLOW STEM <br />EXTRACTION u AIR HAMMER/DRIVEN <br />0 VAPOR MUD ROTARY <br />J AIR SPARGE PUSH POINT <br />0 SOIL BORING g HAND AUGER <br />OTHER: fl OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE IV' MULTIPLE CASINGS? 0 YES [1 NO WELL CASING DIA: — 2e. 4" <br />CASING THICKNESS5C4 4c) TYPE OF CASING: STEEL UPVC 0 OTHER: <br />DEPTH OF GROUT SEAL `) _ TREMIE TYPE TO BE USED: g AUGERS .0 HOSE <br />GROUT SEAL PUMPED: liYes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: EW'LT Pt) e--votkp) D Ltryl ENT <br />APPROX. BORING DEPTH" 54. — Got B,BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ts10 ( if YES, list specifications here): <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 Ordi ances, Rules and Regulations, and all applicable California State Laws. <br />Title/Company STil-FF ENGI EER/gectote miloA3A-L <br />Date 3/22/04. <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: J -3 4i Sr) u-1-1,) <br />WORK PLAN DATED: UV e, 2 1+ ZOO 3 ') Aricigyadv rri +0 work. ()It citiitc-cd ez,envba-r- 30 200 3 <br />/45-9 <br />Final Inspection By ,thideL(,Lf1221/44,Date 4) o4- <br />I <br /> II <br /> k/-1 is/4 <br />-- ...... --- - - • - -- - <br />ACCOUNTING ONLY: AID# r A r`if <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE REQUEST # INVOICE <br />, co <br />O' g9. Do - - <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroach — <br />