Laserfiche WebLink
WELL l RMIT APPLICATION FCQ 1I SITE <br /> �l M:�T� 10—. <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <br /> aplication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appiication is made in compliance with San ,r <br /> laquin County Development Title,Chapter 4-•1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> } `�(4��d'J y }� Assessors / 3 <br /> ELL Location /r LA.(�(64" <br /> p 7�J�Cross Street !`-`� _City Zip Parcel# S � i <br /> 3OPERTY Ownnee+rV U J� C.(L�4" Address z� nNr' Tity� ��y� zip �/� ?r 337(( <br /> •57 Contractor( ' (�-J 1 C&Addre--,'- '' ��`� City��ip'7` a 3Li D Rhene#_/ 5 5/ <br /> )nsultant 1 Sub Cntr Address r>Z�-' S 6t� Ci�-Lic# Phone e*7107 <br /> IS Coordinates:X Y Township Range Section <br /> r <br /> ORK TO BE PERFORMED: i <br /> f�EW WELL/BORING(CPT, GEOPROSE,HYDROPUNCH;HAND-AUGER, OTHER-) n DESTRUCTION(choose type below) I <br /> � l]SOIL BORING# a OVER-BORE <br /> WELL# a PRESSURE GROUT <br /> rther. Grout Specifications: <br /> OMMENTS <br /> 'PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING [j HOLLOW STEIN DIA.OF BOREHOLE,;,"'1MULTIPLE CASINGS?o MULTI-LEVEL?U WELL CASING CIA: <br /> EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS /V';4� TYPE OF CASING: [I STEEL a PVC a OTHER: <br /> VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL/00 Fri TREMIE TYPE TO BE USED: U AUGERS [I HOSE <br /> SH POINT GROUT SEAL.PUMPED: �'S'es d No (NOTE_ MAXIMUM FREE-FALL DEPTH IS 30') <br /> AIR SPARGE/Ozone`�'Pu <br /> SOIL BORING 1]HAND AUGER GROUT SPECIFICATIONS: <br /> OTHER: 0 OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX ar a STOVE PIPE <br /> �\ CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> OMMENTS: 621 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> iereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> ounty Ordinances, Rules and Regulations, and all applicable California State,Laws. <br /> Tned x �� } -_Title/Company 26 <br /> int Nall—'41z; � Date <br /> DEPARTMENT'USE ONLY 1 <br /> ITE MAP IN UNIT IV FILE,ADDRESS: 7 4o&2 r, <br /> IORK PLAN DATED: (;�- / 2-� t) <br /> )plication Accepted By Date Issued I Z00 Area <br /> out Inspection By DateFinat Inspection By Date <br /> !struction Inspection By Date <br /> OMMENTS I CONDITIONS: <br /> kCCOUNTING ONLY: AID# <br /> ?E CODES FEE INFO AMOUNT REMITTED CHECK# RE 'D By DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3 I <br /> -57 WC -WAIVED C-57 Letter of Authoriz ` ion sign permit Encroachment aoc 8/29/02 <br />