Laserfiche WebLink
UID/ L LUUG 14. L] Lb 74 o 0;1L( <br /> E PERMIT A <br /> PPLICATION FIRM SITE <br /> C� MITIGATION <br /> `' SAN JOAQUIN COUNTY UNIT IV <br /> E ,�IRONMENTAL HEALTH DEPARTMENT (EHD) <br /> Cb4 E_ Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 appiication is made In compliance With San <br /> Joaquin County Development Tide,Chapter9-1115.3 and the Standards of San Joaquin county`E,m iro,nmental Health <br /> �Department <br /> �sessor <br /> �t tG' Ci 5l�arcet# <br /> WELL Locationl l-(T�,._Noc"11���.�, —Crossp Street y� tY <br /> Jr(rJ1[ ����Yl res' � }Address f Yl�x Z Llli City I�-+�"J Zi�� c'�one# N/4 <br /> PROPERTY Own`e'r' ,t 1 I q <br /> CSl ContmctortD�t &W b n' j I I arm -PG 8cr `V L 77 7� �� <br /> GonsulWntJSubCanttacto ����d-�reSs-pqc� �`r n'S ^ryr`�V1C✓ `�L;# <br /> GIS Coordinates:X <br /> Y Township Range Sermon <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> Q NEN/WELL/BORING(CPT,GEOPROBE,HPDR C N D AYG�R�OZER�%��,+C���_� Q 0 OVER-BORE <br /> Y�SOIL BORING t/ �U� <br /> 1]PRESSURE GROUT <br /> Q WELL# Grout Specifications: <br /> •Other• <br /> COMMENTS: <br /> E�WELL INSTALLATION TYPE CONSTRUCTION SPECIRCOTIONS ' YES WELL CASING DIA <br /> I]MONITORING Q HOLLOW STEM Dik OF BOREHOLE ILII MULTIPLE CASINGS. Q <br /> 0 EXTRACT10N 0 AIR HAMMERfDRIVEN CASING THICKNESS TYPE OF CASING: llEL []PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> AU <br /> p AIR SPARGE EUSH POINT GROUT SEAL PUMPED: 0 Yes Q No (NOTE, MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING RAND HAND GER GROUT SPECIFICATIONS: <br /> a OTHER: H OTNAU APPROX,BORING DEPTH Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING <br /> PROPOSED?�(if YES,lst speclficatio shere): <br /> Z <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 INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in atcordance with San Joaquin <br /> County Ordi n , es an Regulations,and all applicable California State Laws. <br /> vT 46C C- pany <br /> Signed x <br /> Date <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN 13ATED: "1 U <br /> Application Accepted By <br /> J — Date Issued 1 I 0�— <br /> Grout Inspection By <br /> Data 7 U Flnal inspection By Date- <br /> Destrucfion lnspedon By Date <br /> COMMENTS I GONDMONS: <br /> ACCOUNTING ONLY: AIDX ccr-f► <br /> PE CODES FEE 04FO AMOUNT REPAnr ED CHECK# REC'D B7 DATE PERMrr/SERVICE REQUEST F INVOICE' <br /> SRV <br /> 25/OZ <br /> C-57 WC -WAR <br /> G57 Letter of Authorization to sign permit Encroachment doc` 1/ <br />