Laserfiche WebLink
VVEL L PERMIT APPLICA ROIN FORM SITE <br /> MITIGATION <br /> h0V 0 7 ZOOI SAN .I®A4 UIN COUNTY PUBLIC HEALTH SERVICES UNIT W <br />' ENVIRONMENTAL HEALTH DIVISION (RHS-EHD) <br /> U,"II,�r' " - 304 E.Weber,Third Floor, Stockton, CA, 95202 <br /> FEf- _-' (2€19) 488-3449 <br />' NON-REFUNDt to PERNIR>r71 [RES i YEAR FROM ATE ISSUED <br /> %ppitcabon is hereby madeto <br /> San Joaquin <br /> nr c 11for a 5 3 and thelSta dards of aan Joagconstruct andfor uinl County Publithe work cHea th Serviii Environmental Health bed This appricaton:is made In lDhnseion��San <br /> 1o2quin County a p' Assessor's�rvCa7�.P! aip�Parcel� <br /> VELL Lvcatton O S- Cross Street Lm Crty <br /> II20Pl;RTY Owner �' r'/�' <br /> _ <br /> V. Address 6 ,ty S 'd Z�p 95'Ao�r Phone#�� <br /> 1 Phone# �.i" �-'SBco <br /> ;-57 Contractor L-74� A,oef-46 & Address .� Nv <br /> City Rt �p 3a G: <br /> ;onsuitant I Sub Contractor Address <br /> CIty _ljc# _Phone# <br /> ' Y ,Township _ <br /> Range Section__. <br /> ;I.S Coordinates-x <br /> NORK TO 8E PERFOI7AA [I DESTRUCTION(choose type betow} <br /> NEW Wlrll!BARING CPT EOPROBE,HYDROPU14CH BAND-AUGER OTH!~FY} (j OV1ER->30F�E <br /> SOIL BORING# 13 PRESSURE GFtOUT <br /> ' p <br /> WELL# Grout Spedticatrons: <br /> 'Other CPT BDA/,et�r <br /> .,OMMENTS 2 .SSC A sax <br /> ' �TYpF�OF WELL. INSTAI L�.TION TYPE Coma- tUCTION SPECIFICATIONS /V01VIT <br /> HOLLOW STEM DIA.OF BOREHOLE` .MULTIPLE CASINGS-13 YES *0 WELL CASING Q1A <br /> 1 MONITORING 11 TYPE OF CASING II]STEEL- It PVC (i OTHER <br /> EXTRACTION p AIR HAMMEWDRIVEN CASING THLCKNESS�� tE TYPE TO BE USED II]ANGERS M OSE <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT 5 <br /> 103AIR SPARGE �PUSH POINT GROUT SEAL p1�MPE0 Yes ll No (NATE: �iAMMUi� FREE FALL DEt�"fal IS 3D'� <br /> b b �✓ <br /> SOIL BORING IS HAND AUGER GROUT SPECIFICATIONS CO 0 FIC BOLTED TRAFSOX or Q STOVE PIPE <br /> ' OTHER r PT_—F]�HFFZ APPROX-BORING DEPTH <br /> CONDUCTOR CASING PROPOSED? R/e(a YE3 list apec3ficaGons hare)' <br /> 1% w4 !r011 �e <br /> 'COMMENTS• L- •r <br /> NOTE: OFFSITE BORINGS REOUIRE ACCE11 S11 S 0 R <br /> ENCROACHMENT PERMITS- <br /> CE FOR ALL REQUIRED INSPECTIONS' <br /> CALL THE UNIT <br /> ' IV INSPECTOR 45 WORKING HO HO <br /> !N ADVANCE <br /> I hereby certli I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin s,Rules and Regulations,and all applicable Califomta State Laws GLo <br /> n 4,01 .rr <br /> T,de1company I- <br /> ' Signed x02 <br /> PdntNam ®EpARTIIrIENT U5E ONLY <br /> ' SITE MAP IN UNIT IV FILE,ADDRESS: r 5 <br /> WORK PLAN DATED: I t 6 <br /> Date Issued v —Area� <br /> ' Appricabon Accepted 6y Date Fina1 lnspecdon By Date <br /> Grout Inspection By Date <br /> ' Destruction Inspection By <br /> COMMENTS 1 CONDITION- <br /> SACCOUNTING ONLY AID# <br /> 1 CHECK iF REC'D BY BATE <br /> PEWIT l SERVIC>`REQUEST� tI+tYOECE <br /> PE CODES FEE INFO AMOUNT R��L=D l l s V/ R o <br /> 3 c! `zc o� 1 3$ 43�- 9127,�oa <br /> C-57 WC -WAjVEP,_ C-57 letter of Authorixntion to Sign pertnit Encroachment doc <br />