Laserfiche WebLink
�1 <br /> U 1 San Joaquin County C-Q, <br /> Environmental Health Department <br /> 304 East 1Neber Avenue, 3rd Floor, Stockton, CA 95202 Y 'NGj¢�� AI t f <br /> SIi�A r ' � I' <br /> ' (209)468-3449 Fax (209)468-3433 Web www sjgov org/ehd <br /> a <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED 04 NOV _5 AM 9, 26 <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 9-1915 3 and the Standards of San Joaquin County Environmental Health Department <br /> T Assessors <br /> W ELL Location_5"1 m G Y — cross Street �City y-�--Z1p 4?590 Parcel# I 42� 4�2� <br /> r <br /> PROPERTY <br /> _hN�Q1« Address [v Qdo City -f oCIG(�jZzip95aDZPhone#_ 04 ^�{7 `►79 l <br /> C-57 Contract COS(D�C� �,�isl� Address City C a Zip `f�aLtict�'lr fDPhone#„2Z P �03�IIlo� <br /> of G <br /> Consultant/Sub Cntr 5-:A)f9 Address 1 ;O of 6 City Sn[✓r�w�PctEt ids f'tlone#�l a 7r 0 <br /> IGIS Coordinates X 'Y Township Range Section <br />` WORK TO BE PERFORMED <br /> I EW WELL/ BORING (CPT,GEOPROBE,HYDROPUNGH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> SOIL BORING# a OVER <br /> DIAMETER <br /> WELL# 1V1w-Ak It W- it PRESSURE GROUT <br /> p*Other <br /> GROUT SPECIFICATIONS <br /> COMMENTS I `S i LL_ VyLkIU -S r32 <br /> r TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> i MONITORINGHOLLOW STEM DIA OF BOREHOLEff�2 '0 MULTIPLE <br /> L10 CASINGS Q MULTI-LEVEL WELL CASING DIA <br /> it 111 EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS 1 "S�!�'PE OF CASENG 1]STEEL PVC a OTHER <br /> APOR 0 MUD ROTARY DEPTH OF GROUT SEALII'1', 9f''( TREMIE TYPE TO BE USED Il AUGERS �HOSE <br /> E IR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED --Yes [I No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONSC-- <br /> E [}OTHER p OTHER APPROX BORING DEPTH 112a ` BOLTED TRAFFIC BOX or I]STOVE PIPE CONDUCTOR CASING PROPOSED_ Q_(if YES,list specifications in comment section) <br /> COMMENTS Ll)- ( '+ Q <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Ruleand Regplations, and all applicable California State Laws <br /> Signedx / r Title/Company. <br /> Print Name � �✓U -�_ Date_lam_ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: J „�u v �- <br /> Application Accepted By Date Issued jL- ! -Q` Area 06 <br /> ey <br /> IGrout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS <br /> I <br /> CCOUNTING ONLY TAID# FAC# <br /> IIPE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1 <br /> 2.RD 1J�1 St !I-S SR# 00q,9 <br /> E C-57 ✓ WC ✓-WAIVEP C-57 Letter of Authorization to sign permit ✓ Encroachment doc <br /> EHD 29-02-001 <br /> 9/30/2003 <br />