Laserfiche WebLink
02J23J2001 18.135 21394683433 - _ <br /> FIFTH FL13R <br /> 6 <br /> %WELL PERMIT APPLICATION FORM SIT - <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E.Weber, Third Floor, Stockton, CA., 93202 RR � <br /> (209) 468-3449 �Iv <br /> aWREFO DABLE PKRMIT EXPIRES 1-YEM FROM DATIC ISSUIER <br /> kPIA 2Wn IS hereby made to San Joaquin County for a permrl io construct and/or install the work descnbed TThts application is made in compliance with Sari <br /> Joaquin Counzy Development Title Chapter 4111$3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division <br /> Assessors <br /> dVELL Location jlyLlo 3 <br /> 6.4Qc+ C Cross Street 3�+ no _Gty _ 5 _ k <br /> PROPERTY Owner TD SGd ► Address_ 1 $a+ Lcc�i�,11 r<k S�,I-i 9City �i 7Ip c1S&7 Phorta#. <br /> C-57 Contmctor /� 'lrc Address S :a , /1 _ my v Cs Zip?t1S� Lic* IGb Phone •q'37f- Y+1� <br /> Consultant/Sub Contactor t�ir x-. cart_ 'Kr _Address-p 7��f !ern.C# Gry Q�i1`±ti Lic#Z 2 ' Phonies-iz 5Sf-?-.Snr <br /> GIS Coordinates X-.- _ Y ,Township Range Section <br /> AEMWMWIE�!LITE-O�RI�N-0 <br /> o <br /> 1 CPT,GEOPROSE HYOROPUNCH HAND-AUGER,OTHER-) DESTRUCTION(choaae type below) <br /> I)SOIL BORING 4 p OVER-SORT= <br /> ,XWELLrs KW`� 13 PRESSURE GROUT <br /> 'Other - - - Grout Speoficabons <br /> COMMENTS <br /> F MLL tNSTALLA CONSTRUCTION SPECIFICATIONStt <br /> MONITORING �I IOLLOW STEM DIA.OF BOREHOLI�tULTIPLE CASINGS? �h10 WELL CASING DIA?- <br /> TRACTION a AIR HAMMEWDRIVEN CASING THICKNESS St.%" X10 TYPE OF CASING M L XPVC a OTHER <br /> U-17APOR 1)MUD ROTARY DEPTH OF GROt3T SEALE6`r . TRI:MIE TY?E TO aE USED GAUGERS AROSE <br /> 1)AIR SPARGE IZ PUSH POINT GROUT SERI.PUMPED `�QYes Ii No (NOTE, MAXIMUM FREE-FALL DEPTH iS 307) <br /> 0 SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS_porj la..vr.8 <br /> 12 OTHER n OTHER APPROX BORING DEPTH %- - BOLTED TRAFFIC BOX or ()STOVE QtPE i <br /> !� / CONDUCTOR CASING PROPOSED? {�YES,U�s�abrationshere) L,4 W.k Sfrr- <br /> • <br /> COMMENTS ` $ I tt <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT 1V INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby eeridy that i have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ord T7" <br /> s, Ies an gul ns, and all applicable California State Laws <br /> Signed x / Tltie/Company r �L" rr ~ Clh :r;<. <br /> Print Name Q r s/ r T Date iZ/10 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: /�� �� C✓�t- � <br /> WORK PLAN DATED' ZO • Q <br /> Appilration Accepted By Date Issued D `M Q r +eros 4 <br /> Grout Mspeclion By Date Final lnspect:on By Dat <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS <br /> Ar-c0uwSNG ONLY AIDIt rArt <br /> PE CODES FEE INT=O AMOUNT REMITTED CHECK* REC'D BY I GATE PERMIT I SERVICE REQUEST# INVOICE <br /> ��► _ � a5�a 3� C� 7•z?-o t z oo c� <br /> C-57-- WC -WA1VElt__ C-57 Letter of Authorization to sign per'mlt Encroachment doc 9/27/00 <br /> cctZ :­1 , At rR QA <br /> 2094E8343.q Parc arae <br />