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PR0524710
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Last modified
3/10/2020 2:52:10 PM
Creation date
3/10/2020 10:41:50 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
FIELD DOCUMENTS
RECORD_ID
PR0524710
PE
2950
FACILITY_ID
FA0016591
FACILITY_NAME
VASTI PROPERTY
STREET_NUMBER
5055
Direction
E
STREET_NAME
MAIN
STREET_TYPE
ST
City
STOCKTON
Zip
95215
CURRENT_STATUS
01
SITE_LOCATION
5055 E MAIN ST
P_LOCATION
99
P_DISTRICT
002
QC Status
Approved
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EHD - Public
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Boa°.��•.,�o San Joaquin County <br /> Environmental Health Departm ��� 1UJ�� SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 5 MITIGATION <br /> '.' q'•'•..• .P' (209)468-3449 Fax: (209) 468-3433 Web: www.sjgov.orN/8V _ 9 2005 UNIT IV <br /> Well Permit Application <br /> ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISErt"MIT/SERVICES <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�Ennviirronmennttall Health Department. <br /> WELL Location 7 5 5 �' r 110``� NAV_ City <br /> testa C_LAZ X 9, Z7 Assessors <br /> Cross Street b� I r'1GW Ci Zip Parcel#_ IT -1 om - O-q- <br /> PROPERTYI� I— '/ <br /> Owner _ V-VU S� y/C<S"Il Address l�1 t-I-4 /J• 06'y/�PAia City �s-1 nl. nZip95204 Phone# 4L73 DFj cl <br /> C-57Contractor_ACL&1 D• kau"�\ Addressg0Z IwL.S c.0 l,ya,, City L"Cj Zip Z40 Lic#WPhone# 3(D- 3--D <br /> Y A,S LOG. i <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> XSOILBORING# t —Zp��..�.r,.i�D OVER-BORE. DIAMETER <br /> 0 WELL# d P4E6S6RE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 5" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Z$SOIL BORING *AND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_n OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: Neat 11 (�t wyy,d ClAam -f— <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 accordance with San Joaquin <br /> County Ordina ces, RulesM Regulations, and all applicable California State Laws. '' n Nl I C � <br /> Signed Title/Company �J�YOVirV.-?jv�47J S�.¢ucw-rS�-/ -t- A'S4oc , <br /> ((�� <br /> Print Name t f--tC c 0 Dale I t j &j DS <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 5-057S E- V(ACA f•1— <br /> WORK PLAN DATED:__ 11LjJ0 5r <br /> Application Accepted By Date Issued Area <br /> Grout Inspection ByC,.,r. Date 11115105' Final Inspection By 7--T Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Z`►oI fl ".00 ( q (a ( W tt(fyty! SR# `1 `l T51C <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />
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