Laserfiche WebLink
_ FILE-MY <br /> �}+� .,PERI�IIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> RONMENTAL HEALTH DEPARTMENT (EHD) <br /> EN,VlrtGNN°EN4g4--g-.-r ,eber, Third Floor, Stockton, CA., 95202 <br /> PEWIT/SEIRVICES (209) 468-3449 <br /> � c , <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicaticn is hereby made to San Jca:,uin County for a permit to construct and/or install the work described. This application is made in complianc-e,vith San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Jcacuin County Environmental Health Department. <br /> Assessors <br /> WELL Location 2-(D2 39 M t 11e7 Qe, Cross Street NA City Ese cAkO rl Zip S4 s4 '3Z0 Parcel" 2.2.7 0 yoo3 <br /> roperfies PT "1 .�31 ^81I7 <br /> PROPERTY Owner Berbecian f_ Address 350) Gof�� 2 City /"�oU�es}O Zip �i53sSPnone" <br /> C-57 Contractor /V A Address City Zip Lic Phone',-- <br /> Address <br /> (� /�na�ySiSi714 /IAg;n 5}, City 'scglon Lic"CAR`67?5P hone# $38-9,8ff <br /> Consultant/Sub Contractor roan(.( Toru <br /> GS Coordinates:X Y ,Township �1as Rance C Section 3 <br /> WQRK TO BE PERFORMED: <br /> ,IE,V WELL!BORING(CPT, _CPROBE,HYDROPUNCH,HPD-AUGER,OT'r,ER') DESTRUCTION(choose type_eio��l <br /> [SOIL BORING#_ � 0 OVER-BGF,= <br /> I 0 PRESSURE GROUT <br /> 0 WE`_ <br /> fr <br /> 'Other• Gr Spcifica5ons: <br /> CGMIv1ENTS: BcrAu 13 or n <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIF"!CATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 3" MULTIPLE CASINGS-,0 YES 0 NO WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> VAPCR 0 MUD ROTARY DEPTH OF GROUT SEAL 5—�0 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> p;=iR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes R/No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> VOIL BORING VAND AUGER* GROUT SPECIFICATIONS: (1PA GPs &vk Q M VA ^ <br /> 0 CT-ER; 0 OTHER se APPROX. BORING DEPTH 5-V)" 0 BGLTED TRAF=iC BOX or 0 STGVE'PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES.list s ec;ficabons here): <br /> %( ,; < l4, <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 I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County 0 dinances, Rules and Regulations, and all applicable California State Laws. <br /> SICned X -- <br /> Titl�'Companv Gr o v�A G <br /> _ <br /> Feint Name '0\-, Date��� <br /> DEPARTMENT USE ONLY <br /> L)/C <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 23 23 <br /> WORK PLAN DATED: -0 5 (� <br /> Application Accepted By <br /> Date Issued 1 I 0 5; Area <br /> G:cut Ir.spec;icn Sy ­!�� Date Final Inspection By Datz <br /> Cas:uc:ren IrS::ac::en By Date <br /> CO.'t,!E?;TS!CONDITIONS: <br /> - — I <br /> ACCOUI!TING ONLY: AID" ort <br /> _��^ I FEE AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> � , - �- <br /> IL_�t° � _I_�3 �t �I�3 C� 3•z <br /> A " N -�,�✓ATVFR C-57 Lettr_r of Author i-nticn to Sian permit__ _ Encrccchment dcc 1/2 /02 <br />