Laserfiche WebLink
F11 F <br /> gDrq �, an Joaquin Coufity Y <br /> Cj SITE <br /> y� Environmental Health Department o- �r,;� <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 '! j IGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehdJUN 2 8 2004 UNIT IV <br /> G/FORd <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED..;',- ip.,i�,,; �i'JT HEALTH 3 S <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicaCTdn`66ae in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ssessors <br /> WELL Location Cross StreetCity D21Parce# 2 Z <br /> PROPERTY ��`,�,, tt11 ��_,,.,y.�,_ Zipyf hone# <br /> Owner Jln1'l��lrTN`'�` -Address IOaG {^iYt)1CT'C�YCitySZL�---�L - <br /> =,(., Xlr,�a- C-',Yr c'. citygjna&CjLlzip i /7S/OPhone# 9'I U7 <br /> C-57 Contractor �Address-- - - --- - - - <br /> c#`�_.,,'''"" ,,,�iPhone#-qLp �I� <br /> Consultant/Sub Cntr��Q Address�I It Olri'FIo[erui�_City�LliSuu"uiL <br /> GIS Coordinates:X <br /> y.,Township Range Section <br /> WORK TO BE PERFORMED: <br /> *NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') O OVER-BODIAMETER_ <br /> IAMETER(choose type below) <br /> n SOIL BORING# D PRESSURE GROUT <br /> )KNELL# tll/➢I-a rn -�� GROUT SPECIFICATIONS <br /> Er'Other� <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS !/ <br /> rMONITORING HOLLOW STEM DIA.OF BOREHOLE /D MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA:C2-I/ <br /> cy 9'TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNES33 ,� , TREMIE TYPE TO BE USED: D AUGERS ,HOSE <br /> 0 VAPOR• D MUD ROTARY DEPTH OF GROUT SEAL <br /> n AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: KYes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> n SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 1, OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_D OTHER APPROX.BORING DEPTH -7-0 <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <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 applica ' n and that the work will be done in accordance with San Joaquin <br /> County Ordina s, Rules n egula ' ns, a all applicable California State L ws. <br /> Signed x Title/Company <br /> Date ZZ <br /> Print Name <br /> DEPARTMENT USE ONLY USTe� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: tP 57 <br /> WORK PLAN DATED: (0 <br /> ems— Date IssuedAreae <br /> Application Accepted By ate <br /> Grout Inspection By Date Final Inspection By D <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO <br /> AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# f.3S6T <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit" Encroachment doc . <br /> EHD 29-02-001 <br /> 9/30/2003 ". <br />