Laserfiche WebLink
WELL%RMITAPPLICATION FOFTA <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />NDN -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 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health DivisioR:- <br />Assessor's <br />NELL Location ;1'�►�� NL Cross Street city Zip Parcel# <br />PROPERTY Ow,nerrMe. St�C' � V�� cN1NL Address l 3� N�Mt t 11 u: City �oc�� c Zip?` Phone#1(�1c q-1-1 - 34•-1 11 <br />[;-57 Contractor V w 72•u�. mac. Address �t�.� X Li 1 to CityZ r3 Zip �N I Lic# ICC Phonei-I-G) 777 -Li 1131 <br />CoannsultSub Contractor(ACo K \< S Address -J11% R.uc R City 10 - �t,Lic# Phone# <br />GIS Coordinates: X <br />Y <br />Township Range Section <br />CH!E�CK # <br />J_1v� <br />EC'BY <br />RQ <br />WORK TO BE PERFORMED: <br />INVOICE <br />,G <br />I NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 1] DESTRUCTION (choos below) <br />�DATE <br />7 <br />SOIL BORING #[] <br />ke <br />OVER -E <br />�WELL#tL\.-.�. <br />� u t �PRES UGROUT <br />*Other: <br />Grout Specifications: -e rv,en - <br />COMMENTS: -SeE <br />A n c,, > <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />B MONITORING <br />[I HOLLOW STEM <br />DIA. OF BOREHOLE MULTIPLE CASINGS? Q YES ONO WELL CASING DIA: <br />(� <br />0 EXTRACTION <br />a AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: Q STEEL a PVC 0 OTHER: — <br />[] VAPOR <br />III MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: (]AUGERS [] HOSE <br />0 AIR SPARGE <br />[] PUSH POINT <br />GROUT SEAL PUMPED: [] Yes [] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />[] SOIL BORING <br />a HAND AUGER <br />GROUT SPECIFICATIONS: <br />m <br />[] OTHER [] OTHER APPROX. BORING DEPTH <br />CONDUCTOR CASING PROPOSED? <br />*COMMENTS: '�>LL :JGEK <br />0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />( If YES, list specifications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSNEL; nuNS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordir s, Rule and gulations and all applicable California State Laws. <br />Signed x `` �_. Title/Company cr-co 10 < GQ j G iA�. l/t LGS <br />. _ I. 1 <br />Print N <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted <br />Grout Inspection <br />Destruction Inspection By <br />COMMENTS I CONDITIONS: <br />tti8 W <br />DEPARTMENT USE ONLY <br />Date <br />Q1C-0 Io <br />Date Issued <br />2s zCC <br />Final Inspection By <br />03 <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CH!E�CK # <br />J_1v� <br />EC'BY <br />RQ <br />PERMIT # <br />INVOICE <br />,G <br />L�I <br />�DATE <br />7 <br />�� <br />C-57_ WC= WAIVER_ C-57 Letter of Authci tza�lio to iq� permit K ent doc_ 91zfluu <br />60 3OV6 d007I- EEbE89b6eZ 9S:ET TBaZ/8Z/ZU <br />