Laserfiche WebLink
REAI- h; WE PERMIT APPLICATION kARM SITE <br /> T C 10E <br /> i i <br /> ' ` .fig . - SAN JOAQUIN COUNTY MITIGATION <br /> 35 ENVIRONMENTAL HEALTH DEPART! <br /> UNIT IV ' <br /> 03 MAY 29 FM 12 304 E. Weber, Third Floor, Stockton, A T95 02) <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to constructand/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 /> (` i Assessor's � <br /> WELL Location� Z-5-5 S �A��6t.A ross Street Jt Citytuc i Zip G_Parcel# <br /> PROPERTY Owner.L� ��'� Aeddress �ZS�.S. �r-Fy 1w,,CityZip'I�� Phone# <br /> C-57 Contractor Y r II Address {�O a� _ ry1 r} 5s CK}- <br /> bw� d City Zip�1Lic#�+$SIGS Phone 4 31 .5s"s <br /> Consultant/Sub Cntr V1 6-theawtru"149dAddress 9I6*U City0 Romi4aLic# 539 Phone# b - <br /> .J"ti 7+,1'44-�F Wolf <br /> GiS Coordinates:X' Y` u ,Township -^— -w Range - Section <br /> WORK TO BE PERFORMED: <br /> ­4 NEIN WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ---e HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 MULTI-LEVEL?0 WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS�d TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL-%, f TREMIE TYPE TO BE USED: C AUGERS 0 HOSE <br /> 0 AIR SPARGE/Ozone 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 0 (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH S BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> i <br /> CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> I <br /> 'COMMENTS: <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 Ordinances, Rui s d Regulations, and all applicable California State Laws. <br /> Signed x <br /> Title/Company- <br /> e+ er- ,1, tiv► <br /> Print Name LJ ac' , Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By LAV Date Issued 4,4 Area <br /> Grout Inspection By Date Final Inspection By <br />' Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: iy <br /> I ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT R ! ED CHECK# R C'O Y DATE j PERMIT 1 SERVICE REQUEST# INVOICE <br /> C-57_ WC -WAIVER C-57 Letter of Authop"iza orto sig per it Encroachment doc_ B/29/02 <br /> i V <br />