Laserfiche WebLink
F11 Y <br /> WELL RRMIT APPLICATION FO M SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> 6v� ,) (209) 468-3449 <br /> V <br /> ROC45 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> pplication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliancewith San <br /> caquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> C RohO CAPi�L Avt• Assessor's <br /> YELL Location 114(0'39 N. TI oAwrto Cross Street-36AJTo.. (7nnoCity $ LoO) Zip .59 ZVS Parcel# <br /> 6nKiDES FAvily p WOOP6Ai06h <br /> 'ROPERTY Owner L(.M:ree 0Ar7w,rau#.P Address LO. 00X IYl/ City Zi�►52Sff Phone 4n 16 4S3a <br /> -57 Contractor C45CAjDE DTr 11`9 Address363Z QMEe Ci I kB e <br /> No -7175/o <br /> /yC City CO o�A Zip9S7YLLic# Phoneo/0 / 6 <br /> :onsultant/Sub Contractor NyA&it!A F,..;,,�..,.)i dress Sti7 SHAW Q� . City sfocrron Lic# 68QZZ7Phone#-(2e5) 9_/oollp <br /> ;IS Coordinates:X 'y ,Township Range Section <br /> VORK TO BE PERFORMED: <br /> (NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> WELL# OS-I TMW-I4 W1StMW•16tMW'17rMW HPRESSURE GROUT <br /> Other: Grout Specifications: <br /> JOMMENTS: <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> {MONITORING HOLLOW STEM DIA.OF BOREHOLE 4S n MULTIPLE CASINGS?0 YES ;KNO WELL CASING DIA: <br /> I EXTRACTION II AIR HAMMER/DRIVEN CASING THICKNESS" x�# t TYPE OF CASING: H STEELVC 0 OTHER: <br /> I VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALS o FE£t'b5 TREMIE TYPE TO BE USE 'AUGERS 0 HOSE <br /> I AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ]SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: MI TLM+D /JP�. <br /> OTHER: S <br /> pII�E�P_ 0 OTHER APPROX.BORING DEPTH 7,p FfE';' llBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> Rw'ac 8 — CONDUCTOR CASTING PROPOSED? N• (if YES,list specifications here): <br /> 'COMMENTS: SEF Ae?Ro�.to W OAK PlAn/ da-rev) O9 MAY Zoo?-- <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 Ord'trances, Rules and Regulations, and all applicable California State Laws.. / <br /> signed x r �.J'' — r Tille/ //7 0 <br /> /Company �C T P s:351. <br /> , <br /> ?dnl Name r�M a fl"><<l Cale t'�fF/Z Data <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADe D�SS: l0 7d l�• �� �P <br /> WORK PLAN DATED: /B�CGrt/x S I 0 2 <br /> , a p <br /> Application Accepted By L� Date Issued < Flo z Area '06 <br /> i <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# cnru <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3501 f kw 1732,Y 6f ' sR# D43ez39 <br /> C-57✓✓ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 1/25/02 <br />