Laserfiche WebLink
San Joaquin County <br />Environmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.co.san-joaquin.ca.us/ehd UNIT IV <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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />WELL Location (oa 5[c (a�. Cross Street C��o� City_ 'cLc�lo►. Zip 95,12,0 Parcel# LZ7-641•0`� <br />PROPERTY,/[// <br />Owner t �n� ,c �� oT�trn Address %.3 (Z Scc�f/c�h Cit yy Zip GS32CPhone# ,RDCj T,3jC 39/-34 <br />C-57 Contractor -r r Address Ot ubi r{/(, City Zip Lic#hone# 7,7 <br />Consultant /Sub Cntr /.3 Ili lor,%, w r Address tl� >3 S '16f W Citye�_�Lic# Phone#��j <br />GIS Coordinates: X , Y , Township Range Section. <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) ADESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />0 WELL # APRESSURE GROUT <br />0 *Other / GROUT SPECIFICATIONS AC44 c e,aLz m <br />COMMENTS: fjrc Ci77Acic�c✓ CcJ.-r� ��ct., ,'��*7 G�✓2�c..c✓�.y <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />it <br />PONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z _ <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL -'VC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_ TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICA <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH -- (2' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />/ 1 CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />� <br />COMMENTS:AC2JC —(( - �,d�(�L S.%� (d !;otxdAdaAa4p <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 Ordi e7, Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company t5ee-:hjCi- <br />� <br />Print Name /�.(T Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: %S'9O Fi. a.P©c_ e4' MAR n � 2001 <br />WORK PLAN DATED: 3 la 3 /'n Y <br />Application Accepted By • , Date Issued 3 Z. S' py ENVIE MI-Vr/c% r�=IJ ASI H <br />i� <br />Grout Inspection By `(� ��. Date D Final Inspection By (xt L44' Date O <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P REQUEST # <br />INVOICE <br />3 c�'pZ <br />60.00 <br />.5-4 4 Z <br />3 2,s SROO�; <br />C-57_ W(_ -WAIVER C-57 Letter of Authorization to sign permit_ errr oc_ <br />EHD 29-02-001 <br />9/30/2002 <br />W <br />