Laserfiche WebLink
WELL16:RMIT APPLICATION FO+I 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 t 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 /> 72u0 ciLuv� ` <br /> Assessor's Location SCross Street NDAN Zip95zo 3Parcel# <br /> ORµ A° 1 wew <br /> PROPERTY Owner Add1 <br /> 37 -370 -OI <br /> ress <br /> Zip gSzol Phone# <br /> C-57 Contractor Ca,5. . Z RNK� a <br /> Address 3$5Z Gm�i Cc,v�d Clfy[o-c", Z11)2 Y7-Lic# Phone#C9/s� C3g- IIES <br /> Consultant/Sub Contractor SGc-.L rAIZL� ' ��Address 3c'7 eit5o+_e' v'10� City a Lic# Phone# C9/6�1Y61- cYcr3 <br /> GIS Coordinates:X ,Y ,Township ( 'J Range 6 C Section <br /> WORK TO BE PERFORMED: <br /> a NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) a DESTRUCTION(choose type below) <br /> o SOIL BORING# 0 OVER-BORE <br /> SWELL# k)-7-1 [ /nw-ZZ BPRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> POAONITORING VHOLLOW STEM DIA.OF BOREHOLE /r MULTIPLE CASINGS?BYES gNO WELL CASING DIA:'Z A <br /> 0 EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESS $G4 �Y O TYPE OF CASING: 0 STEEL PVC B OTHER: <br /> 0 VAPOR B MUD ROTARY DEPTH OF GROUT SEAL S/ TREMIE TYPE TO BE USED: ,g'AUGERS B HOSE <br /> o AIR SPARGE 11 PUSH POINT GROUT SEAL PUMPED: O Yes N No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING B HAND AUGER GROUT SPECIFICATIONS:Ne"T <br /> 1]OTHER:_B OTHER APPROX.BORING DEPTH ZS r 913OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?A' (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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed TT--' , Titie/Company fI.oZc=f- ���cSr S`, SEra•t S.Tc�wr+�-+:.-i..� <br /> Print Name 714-t>—"-- y, PA rtatzvt, Date AGN 3i 2 003 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: Z <br /> Application Accepted By Date Issued 03 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By ate <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> cenx <br /> PECODES IFEEINFO AMOUNTTREMITTED CHECK# RECD BY DATE PERMIT/SERVICE REDUEST# INVOICE <br /> 11, <br /> 1K 1314103 SRO 3 ZQµ <br /> C-57_ WC---WAIVER- C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br /> J <br />