Laserfiche WebLink
WELAERMIT APPLICATION AM SITE <br /> MI N <br /> 'SAN JOAQUIN COUNTY <br /> JUN 19 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD)� <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 dAo o ✓', <br /> (209) 468-3449 <br /> ENVIR01%1\'0`1( <br /> PERMIT/SERVICES <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 won(described. This application's madAessessca compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the StandardsMSan Joaquin Tounry Environmental Health cl-,Q0 CtParcel# <br /> Cross Street Ivil_�W'QY City S"COc.K[D/1 Tp "'f .J <br /> WELL Location 10' s' vV, UUr1 c�Sa/SPhone# Z,_ 1-904y3c <br /> 1770 (1 R Ciry'S '01) ' Zr r <br /> eQ FN 4iC.1-�' Address 140 qS 7 Y2.Lic#7/ SJOPhone# l b 1101 <br /> PROPERTY Owner , � 'r <br /> C-57 Contractor C+95CA D� �t//Address 3�3 E Pr� R 5/C %tic# b�Phor 95 76 7 0 )0 b <br /> _ _Address J `2 <br /> Consultant/Sub Cntr� Ranges----Secticn <br /> Township_�--- <br /> GIS Coordinates:X�=Y-�— <br /> WORK TO 8E PERFORMED: DESTRUCTION(choose type below) <br /> Il OVER-BORE <br /> EW WELL/BORING(CPT,GEOPR08E,HYDROPUNCH,HAND-AUGER,OTHER t/ O / w` 0 ASSURE GROUT <br /> 0 SOIL BORING# �y?L <br /> ,p'WELL# —�`-- Grout Specifications: <br /> -OJ /� <br /> COMMENTS n <br /> INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> TYPE OP WELL ----- DIA.OF BOREHOLE JS MULTIPLE CASINGS?OMULTI-LE`/EL?'�j WELL CASING DIA:_ <br /> kWONITORING �Q'HOLLOW STEM ScMFaNIE TYPEOFCASING OSTEEL ` PVC OOTHER: <br /> p EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS ''_1.�5� cc TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 1]MUD ROTARY DEPTH OF GROUT SEALS r <br /> p VAPOR GROUT SEAL PUMPED: es ONO NOTE: MAXIM c EE-FALL DEPTH IS 30') <br /> o AIR SPARGE/ozone a PUSH POINT <br /> � T AN <br /> HAND AUGER GROUT SPECIFICATIONS: �° r-r <br /> j]SOIL BORING APPROX.BORING DEPTH r7.__S __.--�OLTED TRAFFIC BOX or STOVE PIPE <br /> p OTHER: 0 OTHER if YES,list%ufications here):-- <br /> CONDUCTOR CASING PROPOSED.�t�lpr� -rE0Z� '/Vf/{ Y <br /> `COMMENTS: <br /> SE£ AoP ��� Ir��h-, Rf FD�R7, •, <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Titie/Company R n FC 1 <br /> Signed x 1 Date b I Z ,n <br /> ,1 J Cush <br /> Print Name DEPART Mtry I we ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> I01 S, i �, soot (J, . �_6rk4'1, (A <br /> WORK PLAN DATED: Z I 206''3 <br /> 51 <br /> Date Issued oG 27 <br /> l% 3 Area �� <br /> Application Accepted By - - t.c>/ Date <br /> Date Final Inspection By <br /> Grout Inspection By Date <br /> Destruction Inspection B <br /> COMMENTS/CONDrTIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMrr/SERVICE REQUEST# INVOICE <br /> 5779 CN7� �9 03 SR M&Y.3 2- <br /> 35ol ►'�tt1 B/29/02 <br /> C t— <br /> C-57JZWWAIVER_ C-57 Letter of Authorization to sin P ermit_Encroachment doc .N/� <br />