Laserfiche WebLink
WELAERMIT APPLICATION FORM <br /> SAN JOAQUIN COUNTY SITE <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209) 468-3449 <br /> Application is hereNON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joaquin by 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 /> County Developme t Title,Chapter 9-ill 3 and the Standards <br /> ssrof San Joaquin County Environmental Health Department. <br /> WELL Location a6loro �aI ,P� rnV',�) Cross Street+ D -t Assessors � <br /> City 1 zip Parcel# o 9/oo_z y <br /> PROPER } /J �` <br /> Owner 1 e•/' rVl, t^�rj 1 Address 1 , l�OLU;'f city J kd( W(�-2�� �� <br /> II <br /> ZiPi a.7 � Phone# <br /> C-57 Contractor -I Ii Address IDS <br /> —city �i4 zip!t1553 Lic#(0165 Phone#725-313-55 <br /> Consultant/SubCntrS fa�uSFnv 333DC"mfrn+tP4.kOn� SvtliSSo t _ 1o3'Z <br /> {+Y Address Ci MlttUq'gtl(Lic# <br /> Phone#!2 -26(�z <br /> GIS Coordinates:X Y <br /> Township Range Section <br /> WORK TO BE PERFORMED: <br /> 'ANEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> *OIL BORING# t <br /> DIAMETER., ' - D OVER-BORE. <br /> O'Other —' 0 PRESSURE GROUT <br /> SPECIFICATIONS - GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS nO L'.lAQi <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE <br /> 1 t„,,�OMULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_'A t <br /> 0 VAPOR TYPE OF CASING: D STEEL 0 PVC O OTHER: <br /> 'XMUD ROTARY Cp�'�nLJ, DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes 0 LL DE H 30') /j�.( <br /> SOIL BORING o NOTE: M ]MUM FREE-FALL DEPTH IS 30') <br /> O HAND AUGER GROUT SPECIFICATIONS � <br /> 0 OTHER: —0 OTHER _ APPROX.BORING DEPTH 2D' <br /> __.0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: SPQ QI"�^rC <br /> ���(� CON CTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> a� (clw <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 repared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi a tions, and all applicable California State Laws. <br /> Signed x <br /> Title/Company <br /> Print Name /! <br /> DEPARTMENTppUS'E`ONLY Date_ <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Z5 77j- S• lg#kTw ,firII <br /> WORK PLAN DATED: w Area <br /> D <br /> Application Accepted By e/ .6,r�jfpn Date Issued—/4? 4� 4V Q S �5/f'•� <br /> Grout Inspection By Date _ <br /> Final Inspection By <br /> Date <br /> Destruction Inspection ey Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# ��' Q 6 t•( ?7 7 <br /> FAC# <br /> CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# I INVOICE <br /> 3s0/ 9 89 <br />