Laserfiche WebLink
WFLLERMIT AP"PLICATION FN[ SITE <br /> MITIGATION <br /> ;I <br /> SAN JOAQUIN-COUNTY PUBLIC HEALTH SERVICES UNIT 11/ <br /> �r ZQO� ENVIRONMENTAL HEALTH DIVISION (PHS <br /> -EHE) <br /> 304 E.Weber, Third Floor, Stockton, CA, 95202 <br /> '; (209) 458--3449 <br /> -'•`"`: _ NON-REFUNDABLE PERMIT EXPIRES'i YEAR FRdi11i DATE ISSUED ficatian is made in campi[ancs with San <br /> Public Health Services,Environmental Division. <br /> gppfn4on is hereby made to San Joaquin County for a permit to construct andlar install the work desrsibed. is app <br /> Joaquin County Development Title,Chapter 9-11Q15.3 and the Standards of San;Jaaquin County Pte{#Assessor's y� 0 <br /> b�� E 4tJ0d 61G� Cross Street L �2Y1� Ccr <br /> City <br /> WELL Locaticn + <br /> Owner e.�,�rn� Address <br /> rncPERrr l 95�15"ucix G <br /> C-57 Contractor 4119A �iru�m��s fires 7 5 c� city p 7-Ie6 <br /> !' nt,ic-l��l� Prions • � !h <br /> � W — <br /> Consultarrt!Sub Contractor <br /> Address E� Section <br /> Y Towrssh ip Range <br /> GIS Coordinates:X ;i <br /> P51WEEN <br /> O PERFORMED: Q DESTRUCTION(choose type below) <br /> !BORING(CPT,GEOPROBE,HYI}ROPUNCH,HAND-AUGER,OTHOr) OVER-BORE <br /> ASOIL BORING# 1 PRESSURE GROUT <br /> WELL# Grout Specifications <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF L INSTALLATION TYPE CONSTRUCTION SPE C1t"iCA710N51 ' NO WELL CASING 0IA,��� <br /> U MONITORING n HOLLOW STEM DIA OF BOREHOLE_hRULTiPL E CASINGS. 0 YE5 i1 <br /> EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS �[--TYPE OF CASING: Sl EEIw []PVC OTHER: <br /> 0 VAPOR II Muo ROTARY DEPTH OF GROUT SEAL alt ll' --TREMIE TYPE'TO BE USE1a: E)AUGERS 05E <br /> GE PUSH POINT GROUT SEAL PUMPED: 13 Yes �lor �: M MUM FREE-FALL is 30') <br /> p AIR SPAR . <br /> OIL BORING 13 HAND AUGER_ GROUT SPECIFICATIONS: t BOLTED TRp,Fr'1C BOX or STOVE PIPE <br /> d OTHER: OTHE=R APPi�OX BORING DEPTH <br /> CONDUCTOR CASING PROPOSED?_/LVr_(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 INSPECTION S. <br /> i <br /> 1 hereby certify that E have prepared this application and that the work will be done in accordance wi#h Sats.loaquElt <br /> County Ordinan , Rules nd egulations, and all applicable California State Laws. <br /> Tiany <br /> Signed x de/Camp <br /> I 1� � Date Z <br /> Print Name c A <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 5 <br /> WORK PLAN DATED' <br /> Application Accepted ay Gate Issued <br /> na Z Final11nspedlon By � `� <br /> Grout Inspection By <br /> Destruction inspection By Date ; <br /> I <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CORES FEE INFO AMOUNT RI;IIAlITED CHECK# 1REC'D I3Y DATE PERMIT 1 SERVICE REQUEST# IM/OIC>w <br /> C-57 WC -WAIVER C-57.1of Authorization to sign perm i# Encroachment doc___ <br /> 9/27/00 <br /> I <br /> �l <br />