Laserfiche WebLink
cn"..,� San Joaquin County <br /> 2 .'oZ <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.co.san-joaquin.ca.us/ehd UNIT IV <br /> Q4:iK­i2� <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 Environmental Health Department. <br /> As <br /> WELL Location ���"� "Cross Street City 4A _Zip Parcel#essors <br /> JI <br /> PROPE TY Q/ 1 <br /> Owner G V Address I (� G City Zip%�jk�{ Phone# <br /> �' 33 p #1V-3?4-Y3� <br /> C-57 Contractor Address Cit �S Zi �� Lic Phone GG �/ <br /> Consultant/Sub Cntr �Qj� (�/A(• Addresj�� . # Cit6k1kU _Lic# Phone# O'( `f r <br /> GIS Coordinates:X Y Township all; Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/ BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER') Q DESTRUCTION (choose type below) <br /> Q SOIL BORING# OVER-BORE. DIAMETER <br /> Q WELL# ')!�PRESSURE GROUT <br /> Q'Other GROUT SPECIFICATIONS <br /> COMMENTS: -1,4ki4r4 <br /> S- <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Nk-NONITORING '�_UDLLOW STEM DIA. OF BOREHOLE Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS91( TYPE OF CASING: Q STEEL 4rVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL_0^$'f TREMIE TYPE TO BE USED: Q AUGERS iOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes Pro (NOTE: MAXIM M FREE- ALL EP YYH-ISS 30') _ <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS _0 , �1clQS- <br /> 0 OTHER: Q OTHER APPROX.BORING DEPTH O -+KILTED TRAFFIC BOX or VE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: 6 4 S <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certi hat I ve ppared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi ces, les Regulations, and all applicable California State Laws. <br /> Signed x Title/Company [S-_A �[���t b� <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FI ADDRESS: Fly �• WOO 4" (.Uc t2�aw .u.- <br /> WORK PLAN DATED: .2 <br /> Application Accepted B Date Issued lb din 7 Areal_ <br /> Grout Inspection By Date &Lb Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: (� (i �.�. �,Al , <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Cal � J l Jas'� lltk 3 p sR# �p 3 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> EHD 29-02-001 <br /> 9/30/2002 <br />