Laserfiche WebLink
05/04/2004 14 17 2094683433 FIFTH FLOOR I PAGE 05 <br /> S tri <br /> • Y� VIVELL PER MlT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT {EHD} MITIGATION <br /> 1� ooN7^� 304 E Weber, Third Floor, Stockton, CA , 95202 UNIT IV <br /> JAty�pI�O ,yrs «L'S (209) 468-3449 <br /> � NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appl,cat,ar 5�ere6y made to San Jaaqu,n county for a parm d to construe'andlor rnztelf the work doscr,bed This epplioation,s made in compliance with San <br /> Jaaqucn County Development Title Chapter}t,15 3 and the S'andards&San deaqurn County Environmental Heolth Department <br /> �I <br /> U <br /> �1 Assessors <br /> WELL Location 56,00 'e'- <br /> y- 4CLY` U Cross S reet S�, City c tine 1f dip �rS33c�Parcel# 1 6 <br /> PROPS p L5 <br /> TY�.\ �p <br /> Owner Wlq\t\ ✓'TC1.�16d Add,ess fSlo s ?&Ity�ZIP Phone 6F- , 1}l—3 p <br /> �n J Address 175' lkweI c, rlNct�t �n�x <br /> ty Zip � Lle� Phon_ <br /> Consultant lSub Cntr�`Fi`tCa'kVS LL1Ll, Addrsgg �� <br /> GIS coordinate$ X YTown5hlt7 ��� Range P Section <br /> WORK TO D PEi FORMED <br /> 0 NEW W9LL 1 BORING <br /> +Y_F T,_G.EOAP_ROBE HY ROPUNC3-jHAND <br /> �AUGEP,OTHER-) 13 DESTRUCTION (choo..s._e <br /> type below) <br /> OIL BORING# f]OVER-BORE DIAMETER <br /> U WELL# <br /> D PRESSURE GROUT <br /> D"Other GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL, INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING 0 HOLLOW STEM DIA OF QDREHOLE Z ' 0 MULTIPLE CASING$ D MULTI-L3-VEL WELL CASING DIA <br /> •0 EXTRACTION 0 AR HAMMERlf1RIVEN CASING Tm CKNESS 7YPE OF CASING 0 STE.»L D PVC TJOTHER <br /> a VAPOR 0 MUD ROTARY DEPTrl OF GROUT SEAL TREMIE TY"'E TO SE USED 0 AUG=—FS a HOSE <br /> D AIR SPARGE!OZONE PUSH POINT(G?or CPT)GROUT SEAL PUMPED 0 Yes 0 No (NOTE MAXIMU M FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GRGUT SPECIFICATIONS p _ <br /> []OTHER 0 OTHER APPROX BORING DEPT �D TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR ZASING PROPOSED (if YES IstSpec;ficabDns,ncommentsection) <br /> COMMENTS _ <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done in accdrdanCe with San Joaquin <br /> County Ordinances, Ru1e�and Regulations, and all applicable California State Laws <br /> Signed x G �jr T,tte1Company � E 'SY�[lr7�Yt pNe�ti. C±Jr P�a� 5f <br /> Print Name. r fL i'"y Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS' JS�05 <br /> WORK PLAN DATED to j ! 0 <br /> Application Acz;eptey .�/`id 13yyt ► Date Issued r � 7 _- — Area 7 J <br /> Groutlnspecton 9y Date Flral Inspection By Date_ <br /> bestz,ct,on Insp:ctlon ay bate <br /> COMNII<NTS I CO NDITIONS <br /> ACCOUNTING pNLY AID# rAC� <br /> PE CODES FEE INFO A14OUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> C-57 WC -WATVC12 C1-r7 Leber of ,'�fhoMZOt,on to bigr perrni t,____„ Encroachment doe,_„ 9/30/02 <br />