Laserfiche WebLink
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 />ORIGINAL <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 />.niqtrIvi• Assessor's <br />WELL Location 19 /9q THe R 41•1 RJ • Cross Street Cetipe:10L Ave. City L0 1 Zip 15.eN Parcel# 055 .- Z%r, <br />PROPERTY Owner Ai a 1 -ZAP'S KANn • PAoiLtai Address Pc, 8Q x City [AOC-) Zip 95•kr Phone <br />AtINcl-k•A <br />C-57 ContractorC4SL•iDE <br /> <br /> Address amtc, Clitie City cf.; Rae., rt zip55 79Z Lic# 7/75/C) Phone#(94) 6-5(r-- <br />J <br />8--; Consultant/Sub Cntr A ,G ,E. Address 7 • City 571410Dr1Lic# 4elooVi Phone4c.9 9/) 7 -A 0 <br />GIS Coordinates: X , Y , Township 3n/ Range 6.E. Section /V <br />WORK TO BE PERFORMED: <br />ANEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER-BORE <br /> <br />)1f,WELL # It4W-7 i mw-is _ ['PRESSURE GROUT <br />*Other: MN-44-i ; , rn Iv • 1 1 vv - / 2., Grout Specifications: Po A Ti... AND TypE II <br />COMMENTS <br />3,;?-. 778° Cj <br />5. APPRvzi) Lfrsi oRK 16iv Pi3 -a0 6;13 .1)1 c7c-1 <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />MONITORING OLLOW STEM <br /> <br />0 EXTRACTION B AIR HAMMER/DRIVEN <br /> <br />0 VAPOR <br />0 MUD ROTARY <br />fl AIR SPARGE / Ozone El PUSH POINT <br /> <br />SOIL BORING U HAND AUGER <br /> <br />OTHER: ['OTHER <br />*COMMENTS: S E E ()PPP jD <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE " MULTIPLE CASINGS?)(MULTI-LEVEL? D WELL CASING DIA: <br />CASING THICKNESS TYPE TYPE OF CASING: U STEEL U PVC OTHER:T4F/c4A) <br />DEPTH OF GROUT SEAL 35 FU+ TREMIE TYPE TO BE USED: UGERS U HOSE <br />GROUT SEAL PUMPEDXYes U No (NOTE: MAXIMUM FREE -ALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: „I -1,1N° 7--- <br />APPROX. BORING DEPTH ) FT 85 <br />CONDUCTOR ats,II\IG PROPOSED? ( if YES, list specifications her): <br />IMOR K ?On), De9-TeD 3 3.)1 k oc <br />BOLTED TRAFFIC BOX or [1 STOVE PIPE <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 <br />County Ordinances, Rules and Re ulations, and all applicable Californi tate Laws. <br />oc.) T GE-Ls/C*37 <br />J. <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: /V7V9 K9244.14X. 4/ <br />WORK PLAN DATED: 72.) <br />Date Issued /— P-0 3 Area 6148)1. <br /> Date / 0,1u43 <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE -, - • 1* • # <br />DSO I AAA el ing t/ at-t F. J. / e el ( 0 37-33 g" <br />C-57 V WC 7-WAIVER <br /> <br />C-57 Letter of Authorization to sign perm croachment dpc 8/29/02 <br /> <br />prepared this application and that the work will be done in accordance with San Joaquin <br />Signed x <br />Print Name <br />Title/Company <br />Date c.v.03— 3 <br />Application Accepted Accepted By <br />Grout Inspection By Date Final Inspection By <br />Date