Laserfiche WebLink
WELL PAMIT APPLICATION FOR16 SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 n <br /> (209) 468-3449 - tj T/fiy� <br /> NON-REFUNDABLE PERMIT EXPIRES YEAR FROM DATE ISSUED <br /> plication 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 /> hquin County Development Title,Chapter 9-1115.3 and the Standards of Sai.Joaquin County Environmental Health Department <br /> ,r // �( p �Zd T Assessors <br /> _LL LocatlonZM11l Nq GST LF�A/fC, Cross Street,ralFlt�4� City 571tk-T6h/ L Parcel# <br /> OPERTY Ownej TAT&L-NU.44C Address&yl 4. Wnf 7 � Clty S��l��pKTJX Zp EP4( Phone# <br /> 3 Contradorl"IITC+t�CLl- L.�t[.LLgt�(L�Y Address J S. kr w /,1;U/��. Cri�fy�� 2P. `Alp Lic#6-�' 1 Phon `lIG 631 3 3 <br /> nsultairt/Sub Contractor RD�4WCE0NFeFiIVtCOel.�fk47/N�Address b�`7 7't�—AAL City Sr«'�Lidi 5AW7 Phon,#Lze ) 6 7-/,b& <br /> 3 Coordinates:X ,Y.Township Range Section <br /> )RK TO BEP RFO MED: <br /> JEW WELL BORIN (CPT,GEOPROBE,HYD PUNCH,HAND-AUGER,OTHER-) ®DESTRUCTION(choose type below) <br /> ,SOIL BORING# AP 1 o OVER-BORE <br /> 1 0 W ELL# I6 PRESSURE GROUT <br /> their Grout Specifications: <br /> )MMENTS: _ <br /> PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ,�/' <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE rr MULTIPLE CASINGS?Q YES 1YLJ0 W ELL CASING DIA: <br /> XTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS A TYPE OF CASING: 11 STEEL a PVC 0 OTHER: <br /> 1APOR a MUD ROTARY DEPTH OF GROUT SEALTu!A'L TREMIE TYPE TO BE USED: []AUGERS 0 HOSE <br /> AIR SPARGE 0 PUSH POINT 'GROUT SEAL PUMPED: XYes u No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING p HAND AUGER GROUT SPECIFICATIONS: DP- t-D T .L <br /> OTHER: tl OTHER APPROX BORING DEPTH r BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 2 <br /> CONDUCTOR CASING PROPOSED? 0 (if YES,list specifications here): <br /> OMMENTS:�J c�761L d n�,LrJ �'(CI JAI 1, / Tl UAIA ISI 71 S FhGES <br /> ?yz ,,CIEs ->'D � I�QrIRsnC�.n t�j.TN �'�ef-i-r <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 /> lereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> auntyInanc'`e��7s, Rule and Regulations,and all applicable California State Laws. /1 <br /> Ined x ^ 77�J�`�,,rc Title/Company,5-rA Lf ,*S7/Ab)�� <br /> int Name 1 - 17 tti`u Date <br /> DEPARTMENT USE ONLY <br /> TE MAP IN UNIT IV FILE,ADDRESS: <br /> ORK PLAN DATED: /� lI <br /> plicadon Accepted By .fCr I QU 1 \ � � Date Issued L 1 zoo ` Area <br /> out Inspection By Date Final Inspection By Date <br /> �struction Inspection By Date <br /> )MMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# cern <br /> 'E CODESI FEE INFO AMOUNT REMITTED CHECK# EC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> of q o sR# o R <br /> -57_ WC_-WAIVER_ C-57 Letter of Autho i n o signnpermit—Encroachment doc1/25/02 <br /> 'y 0 V""v <br />