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2900 - Site Mitigation Program
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PR0516739
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Last modified
2/14/2019 10:37:37 AM
Creation date
2/14/2019 10:25:10 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
FIELD DOCUMENTS
RECORD_ID
PR0516739
PE
2950
FACILITY_ID
FA0012765
FACILITY_NAME
GLEASON PARK PROPERTIES
STREET_NUMBER
0
STREET_NAME
CALIFORNIA
STREET_TYPE
ST
City
STOCKTON
Zip
95203
CURRENT_STATUS
02
SITE_LOCATION
CALIFORNIA ST
QC Status
Approved
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EHD - Public
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• r • <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> `+ I 304 E. Weber, Third Floor, Stockton, CA., 95202 E, Copy <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 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 Public Health Services,Envircrmental Health Division. <br /> Assessor's <br /> WELL <br /> WELL Location 925rS�1".Fo ,; Sr`. f Cross Street/City S kTo� Zip tfZ Parcel# <br /> PROPERTY Owner doh fnn co Address 71,en/ r,✓o +'✓z City ST�Zip 9520% Phone# �Z /16- "45 <br /> C-57 Contractor T 1m'.+a LoLcroLr'ts Address •4527 Fresno sTeCr City fiesnD Zip 3?21 Lic#50G!51 Phone# ('S5932b <br /> Consultant/Sub Contractor Tw'n_,p La6nr4r , 7 ero er Ci <br /> e !`res✓.o Lic# Phone# (53'732(0'= OZ/ <br /> GIS Coordinates:X ,Y ,Township / Aio rib Range r E sT Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH, AND-AUGE OTHER-) 0 DESTRUCTION(choose type below) <br /> I SOIL BORING# - -// 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> ;]AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING /HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH ".-7' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <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, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title1Company 7�/'00m M-4..5 <br /> Print Name A Date Ocv f <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> Date Issued Area b b `Rt <br /> Grout Inspection By <br /> Date Final Inspection By Date <br /> - <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# :_ REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> MIT <br /> Zoo SI3 d Z 2-Z8 0) DD 253 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />
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