Laserfiche WebLink
10/21/2003 10:38 2094671 r AGE STOCKTON <br /> alopy <br /> ipt-1 AL HEALI it <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY NIITICaATION <br /> 03 OCT 21 AM IO: 36 ENVIRONMENTAL HEALTH'DEPARTMENT (FHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNnA6 17 EXPIRES 1 Y1:AR FROM DATE OUtp <br /> Application is hereby rade to Sart Joaquin County for a Permit to construct and/cr instatl the work described, This application is made In compliance with SE <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environme�ntall Health Department_ <br /> VW-LL LOCbtivn Z/�9��D/1 I` l�/G$OiI�/f' Cross Streat_/4KO' V City ?U— `ZAP p�,��parcel#Assessors/r /vT Z <br /> PROPERTY Owner-Y„ �/�2{S.. Address g � �i uil City • GC(C��� lip J�7+'�J Phone#/ <br /> C-57 Contrac*r CJ6�) Address.0_3 7 A4� AW City <br /> Consuttarit/Sub Cntr Address City LJc# Phone# <br /> GIs Coordinates:X ,Y ` Toms yp � Range Secucn <br /> TO BE PERFORVEIp: <br /> WELL/BORING(Q1 T,GEOPROBE,HYDRO NCH,HAND-.AUGER,OTHER a DESTRUCTION(&nose type beta <br /> SOIL BORING# Q OVER-SORE <br /> WELL# -� Q PRESSURE GROUT <br /> Grout Specifications: <br /> COMMENTS <br /> 1 <br /> TYPE OFyVELL INSTALLATION TYr�F CONSTRUCjION SPECIFlCATtONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?a MULTI-1.EVF.,L7 0 WELL CASING DIA: <br /> Q EXTRACTION ll AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: n STEEL Q PVC U OTHER:— <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 90 TREMIE TYPE TO BE USED: VALIGE:RS 0 HOSE <br /> AIR SPARGE/Omne PUSH POINT GROUT SEAL.PUMPED: Q Yes a No (NOTE: MAXIMUM FREE-FALL DI~PTH IS 30 <br /> SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: ,&A �'1C6ri r _ <br /> I OTHER:_ . d OTHER APPROX BORING DEPTH ?-d a BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?-(if YES,Ilst spedtications here): <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE,FOR ALL REQUIRED INSPECT70NS. <br /> hereby certhY that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> :ountyOrdi ces, ul® nd Regulations,and all applicable California,State Laws. <br /> ignedx Titlelcomparry il/Ll//�aR�'� iL <br /> rtnt Name Date 40,4v _O' <br /> DEPARTMENT-USE ONLY � <br /> .ITE MAP IN UNIT IV FILE,ADDRESS: 3.z�y Gv A - &4 . 5;r,Z_ <br /> rORK PLAN DATED: S G 7 / <br /> 3PAcatkm Accepted Sy Date Issued 3 Area ®�p� <br /> rout Inspection By <br /> Date Rnal Ir>apecticn Date <br /> mtruction Inspection By Date <br /> 3NMUNM J CONDITIONS: <br /> 1CCOUNTING ONLY: AID# <br /> IE CODES FEE INFO AMOUNT CHECK# RECD 13Y DATE PERMIT J 5ERVICE REQUEST# iP1VOtCE <br /> 1 8q 3/ d!:'/ I d003585 <br /> -57— WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc� 8/29/02 <br />