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3500 - Local Oversight Program
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PR0544510
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Last modified
5/31/2019 2:28:09 PM
Creation date
5/31/2019 2:16:36 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
3500 - Local Oversight Program
File Section
FIELD DOCUMENTS
RECORD_ID
PR0544510
PE
3528
FACILITY_ID
FA0002715
FACILITY_NAME
NEWARK RECYCLED FIBERS
STREET_NUMBER
800
Direction
W
STREET_NAME
CHURCH
STREET_TYPE
ST
City
STOCKTON
Zip
95203
APN
14523004
CURRENT_STATUS
02
SITE_LOCATION
800 W CHURCH ST
P_LOCATION
01
P_DISTRICT
001
QC Status
Approved
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EHD - Public
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P. 3 <br /> 1-28-2000 2:41PM FROM _ <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> FE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES WE.�l <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 JAN 0 8 2001 <br /> (209) 468-3449 ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERM IT%SERVICES <br /> oplication 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 <br /> an Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public.Health Services, EnvironAssessorHealth Division. <br /> ' Cross Street Sloc h X -5 City. t r d Zip `I52 Parcel# <br /> TELL Location 1960 QIes+ <br /> ROPERTY Owner �� '�'� 1`51 i e' '�L� �R I°cr�C Address ';4ocki O i1 City c Zip��S ZC.),3 Phone# <br /> 71001 <br /> 1��.,,.�.,,.,l.� l):•,I1,oA 0.Address I� ( 3311 City' j' c Zip I�A)i-V--- —�- <br /> 57 Contractor Zj /L <br /> Addressl�l�J fcCt'�r%7q lam( City Phone# T�3 <br /> onsultantI Sub Contractor 14AR(Jiyt►E: FS_� A , <br /> Y ,Township tO Range � Section <br /> ho <br /> ;IS Coordinates:X <br /> VORK TO ..E PERFORMED <br /> DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPT, GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER`) 0 OVER-BORE <br /> 0 SOIL BORING# PRESSURE GROUT <br /> p WELL# _ , <br /> Other: Eu, <br /> 'OMMENTS: <br /> 1 <br /> rYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 6 r MULTIPLE E OF CASING STEEL YES O WELL <br /> LPVC B SING DIA. Z.I <br /> ]EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS /��I. <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS BHOSE <br /> 3 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPPJ 30') <br /> 0 <br /> 0 SOIL BORING p HAND AUGER APPROX. BORING DEPTH BOLTED TRAFFIC BOX or 0 STOV PE <br /> Q OTHER: __ 0 OTHER CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> COMMENTS: <br /> NOTE- OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS _ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances State La <br /> Rules <br /> San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance oft work <br /> and Regulations of the issued, I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hirir b- <br /> for which this permit S e performance of the work for which this permit is issued, f shalt employ persons subject to <br /> contracting signature certifies the following: "I certify that in th <br /> WORKERS'COMPENSATION Laws of California." <br /> CALL THEUNI 4v INM ECTOnR/48 WORKING'HRS'IN AQDVANCE FOR ALL REQUIRED INSPECTIONS. <br /> /`, C� Title/CompanY1' OG%`}TECPO� rS7�Ir�!/i�r✓ ��� <br /> Signed x (� <br /> Print Name (nr4rY lJ� !-� EC K, p( Date} /(Q/ Z / <br /> • .rC-a�-� U1` „'I Y �WQ1-1�It�t .L11 �r <br /> ..1_.'._._.0 �6.-,+,...1,...........`.civ., .1......a._•-_�r.__�_.ra4» .. _.. <br /> ti.,.. r..7 ......- .. <br /> _ DEPARTMENT USE ONLY C / V <br /> Application Accepted By ' `�c• Date Issued �. ( Area <br /> Date Final Inspection By Date <br /> Grout Inspection By I l�e�Ar <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTIN=AMOUNT <br /> PE CODES ED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1 L <br /> U <br />
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