Laserfiche WebLink
01/15/2004 14:34 <br />2094683433 <br />FIFTH FLOOR <br />WELL PERMIT APPLICATION FORM <br />.JUN 1 I jUU4 SAN JOAQUIN COUNTY <br />kI0FiuNIvItNT f�q�INVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />PERMIT/SERVICES EALI104 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />PAGE 02 <br />SITE <br />MITIGATION <br />UNIT IV <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 />_ L / ASSE350r <br />N f 1n,�us�l✓Iq�Gk J� Cross Street U . City O� l Ol/I 7�iP S I �QdfCeir w J �v <br />WELL Location ^S, It�� o _ f - f '/ q c <br />PROPERTYOwnerlV ✓ 1 cdd(1Vc QCT Address DO N wugvie✓ Aue. city -io f� a p 3i,Phone#(ao9 <br />i' , �. �. �ox INS .Co �dl�clty�Q�,,ovu z iS6Y8uax Phonei���Uleo'� -d8'2� <br />C�57 Contractor vv L � 0 vat Ove Address ` .�.Tj � � ( p q <br />Consultant! Sub Contractor ZI��P (�A..�S o U y4,,yddress VCS 1 [ VA_ CityE��/ ✓ c# J`60 /{ aZ Phon 7�� ( o� Sty % <br />J Township I �y Range 7 � Section SPC �J <br />GIS Coordinates: X . Y --- —... _ <br />VORK TO BE PERFORMED: DESTRUCTION (choose typ:: Below) Z <br />NEW WELL / BORING (CPT. GEOPROBE. HYDROr'UNCH, HAND -AUGER, OTHER') 11 Oyose ty RE <br />tSOIL BORIN9# o PRESSURE GROUT U <br />W ELL # <br />'Other Grout Specifications: <br />COMMENTS: _ -- —eb <br />TYPE OF WELL <br />INSTALLATION TYPE <br />1] MONITORING <br />0 HOLLOW STEM <br />*EXTRACTION <br />AIR HAMMER/DRIVEN <br />11 VAPOR <br />/1] <br />UO ROTARY <br />0 AIR SPARGE <br />1] PUSH POINT <br />II SOIL BORING <br />[] HAND AUGER <br />I1 OTHER: <br />0 OTHER <br />'COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA OF BOREHOLE% ' MULTIPLE CASINGS? p YES 10 WELL CASING DIA:- 'h <br />CASING THICKNESS C C TYPE OF CASING: ❑ STEEL �� VC 1] OTHER:_ <br />DEPTH OF GROUT SEAL 3 ' TREMIE TYPE TO BE USED: Q AUGERS NOSE <br />GROUTSEALPUMPED:r�Yes Na (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />Ce�—F-,+ <br />GROUT SPECIFICATIONS: Z <br />APPROX. BORING DEPTH G ' - BOLTED TRAFFIC BOX or 13 STOVE PIPE �+ <br />CONDUCTOR CASING PROPOSE[)? � (if YES, Inst 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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordi s, Rules an gulations, and all applicable California State Laws. / I I <br />Signed <br />J e�V l I 1 e Titletcompany �✓ U 1 i <br />(/ I/ I ✓ Date 5 'Z U <br />Print Name L� AuyGl� r I ^"`w'^ t �4 �� _ „-,r..­a 11r• . 1rr- v <br />SITE MAP IN UNIT IV FILE, ADDRESS:_ <br />WORK PLAN DATED: <br />AppliCatian Accepted 8 Elate Issued <br />B <br />Date - <br />Grout <br />g� <br />Grout Inspection y <br />Date 1, 0 Final Inspection By <br />Destruction InsptY. <br />Date <br />COMMBiIT$ I Cw U <br />[ACOUNTINGAID#ODES AMOUNT REMITTED CHECK # REC'D SY DATE P 3ERVIGE R # INVOICE.01 D1 O� �(� / sR 0b $8 <br />C-57 WC-WArVER C -5f Letter of Authorization to sign permit croachment d <br />i/25/ <br />