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COMPLIANCE INFO
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EHD Program Facility Records by Street Name
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STOCKTON
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2900 - Site Mitigation Program
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PR0516708
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COMPLIANCE INFO
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Entry Properties
Last modified
6/15/2020 2:29:06 PM
Creation date
6/15/2020 2:25:25 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
COMPLIANCE INFO
RECORD_ID
PR0516708
PE
2950
FACILITY_ID
FA0012750
FACILITY_NAME
ROBERTS METAL INC
STREET_NUMBER
1803
Direction
S
STREET_NAME
STOCKTON
STREET_TYPE
ST
City
LODI
Zip
95241
APN
06219017
CURRENT_STATUS
01
SITE_LOCATION
1803 S STOCKTON ST
P_DISTRICT
004
QC Status
Approved
Scanner
TSok
Tags
EHD - Public
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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD),., UNIT IV <br /> 304 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 application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> C I Assessor's <br /> WELL Location I g07 �' .�U.�b�'1 5t Cross Street keh leMGn Lwnt City LOd( ZipParcel# tI / <br /> PROPERTY Owner��I1 �(( � Address �70�u'ut ' SVlUlt'S Pkv City i`( LJ6&Zip 05-Phone# 7 t+-oioy <br /> C-57 ContractorP QkbiJ (eLf-nur��rrt.' a�Address�5,� S k"Pl CityS ✓, Zip 9Q6—Lic#(Q2,2�Phone �100f, <br /> Consultant/Sub Contractor !SAME ks A&OUE Address City Lic# Phone# <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION (choose type below) <br /> .SOIL BORING# 0 OVER-BORE <br /> []WELL# 0 PRESSURE GROUT <br /> "Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING G HOLLOW STEM DIA.OF BOREHOLE?" MULTIPLE CASINGS?OYES ONO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS /Vim` TYPE OF CASING: 0 STEEL 0 PVC H OTHER: <br /> 0 VAPOR • 0 MUD ROTARY DEPTH OF GROUT SEAL j'-i! TREMIE TYPE TO BE USED: 0 AUGERS <br /> 0 AIR SPARGE ,n PUSH POINT GROUT SEAL PUMPED: 0 Yes RNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: °1 I� �65 <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH (5 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <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 Ordi nces, Rules an egulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name 1 1 Date '-;11-0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By_ Date Issued /CJ/� AreaS� <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ll7 rd� o/ SR# b o a SZ.d o <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />
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