Laserfiche WebLink
%an Joaquin County • <br /> Environmental Health Department . <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> '•f (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <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 9-11115.3 and the Standards of San Joaquin CountyEnvironmentalHealth Department. �1 <br /> WELL Location 32(`7 �'( U J.11da(k Cross Street v Ul' City ^, Zip _Parcel#Assessors <br /> PRP � <br /> OwnOerERjU� WV I I'I I J Address tY1 I/7 y` p_ -��q - <br /> 1 6 llNI V yCit J Zi 95 Phone# 2D I <br /> C-57 ContractorILKAd 111 - Address Jv32 ec Ci'rrcle CityLL Zip �J� ZLic#-7P Phone# t t(�I /-I <br /> Consultant/Sub Cntr CLQ 1 � Address l��(0S Mfr G'�'f�"I+W' l)utiity )qe ALic# Phone# 7�y—L{��l"f 1U) <br /> ,? f <br /> GIS Coordinates:X 315 ��el t1j/ _,Y �1�� 1� /I�,� township I (y Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION (choose t erl�elow) <br /> a SOIL BORING# ER-BORE. DIAMETER /_ <br /> WELL# PRESSURE GROUT <br /> a*Other �n , I_ M U JGROUT SPECIFICATIONS <br /> COMMENTS: �L�( ;�I 1 U LMA MOL _3 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SP CI (CATIONS <br /> Q MONITORING a HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS u MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL OVC 0 OTHER: <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS a HOSE <br /> Q AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: a OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 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 Ordinanc9j,,ftPles and 114p6lations,and all applicable California to Laws. �r� ICIVA <br /> Signed x v l�Title/Company � 6 <br /> Print Name aom l i' Ul UA-v) Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED::�/� <br /> Application Accepted By 1GGZ�a�i P �L�� a'1 l�+ j'� �� f� Date Issued Area <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Q "� 1 � viDate l --�jK <br /> COMMENTS/CONDITIONS: ����`' � 3 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ily. 7.2 �D P� -237J ��7 OG SR# <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 F� 060 <br /> 60 <br />