Laserfiche WebLink
Ib � <br /> IT APPLICATION FOSITE <br /> 111� L- PERM W . <br /> ,SAN JOAQUIN COUNTY MITIGATION <br /> 4 IRONMENTAL HEALTH DEPARTMENT(EHD) UNIT IV <br /> s - Liv <br /> Weber, Third Floor, Stockton, CA., $5202 <br /> (209)468-3449 ' <br /> I+IONEFUNOABLE PERMIT EXPIRE51 YEAR FROMDATE ISSUED <br /> plication is made in compliance with San <br /> Application Is hereby made to San Joaquin County tar a permit to construct and/or install the work described. This ap <br /> Joaquin County Development Tittle,rChapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. rs <br /> WELL Locatlon <br /> D �LA.ST Gbh� Crass Street �ice. City� G Z.iP � �Pam 2�i�—3bg Z2 <br /> PROPERTY Sin ����Cls'pen tty�n Zip�Phone# <br /> Owner Lam. Address <br /> (�,CCE onsuitant �SC � �--- JCS zipaM� # Phone#(-�l CZZS�S -1 <br /> 0 <br /> 0 <br /> D <br /> C-57 Contractorr1Address <br /> TY2SG0 <br /> ty <br /> ub Cntr d <br /> X <br /> Y wnship Range Section <br /> GIS Coordinates: To <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER') fl OvER- BORE- DIAMETER <br /> SOIL BORING# U PRESSURE GROUT <br /> WELL#_Pj0---2i Z- GROUT SPECIFICATIONS <br /> *Other <br /> COMMENTS: <br /> TYPE_ OF F WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATI µ <br /> �MONTTORING *HOLLOW STEM DIA.OF.BOREHOLE_.n [I MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OFF CASING: STREMIE TYPE TO BE USTEEL ED: p A THEGERS HOSE <br /> II VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL�[2' <br /> AIR SPARGE!OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes.-. 0 No (NOTE: MAXIMUM FREE-FALL DEPTH 1S 301) <br /> n SOIL BORING n HAND AUGER GROUT SPECIFICATIONS_—. <br /> p OTHER: �l OTHER APPROX.BORING DEPTH Z 5 BOLTED TRAFFIC BOX or [)STOVE PIPE <br /> CONDUCTOR CASING PROPOSED A 2D (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 INSPEIMO <br /> „a <br /> I hereby certify that I have prepS. <br /> ared this application and that the work <br /> kwill be done in Laws. accordance with San Joaquin <br /> County Ordin d Re ons,and all applicable California <br /> F Title/Company <br /> Signed x <br /> • Date, — <br /> r Print Name DEPARTMENT tO NL <br /> :Y <br /> SITE MAP IN UNIT IV FILE,ADDRESS: V c <br /> WORK PLAN DATED: 0 <br /> Date Issued Area <br /> Application Accepted By to <br /> Final Inspection 8 <br /> Grout Inspection By Date 7 <br /> Destruction Inspection By Date r <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 4.03 s 3 - <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign per Encroachment doc 9/30/02 x <br /> FILE <br /> COPY <br />