Laserfiche WebLink
WEIVERMIT APPLICATION INRM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <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 />WELL Location/61- KJ- I, yer-zm 4c- Ave,.Assessors <br />Cross Street& UO/0)9 1-?ri City 4-40-nit e.C( Zip <br />PROPERTY , <br />Owner Ti-V.MVIS itifte)cj Irt.)0Ytj Address „2.V67 kJ-60cl rider CityPiettgthfrbK <br />Citylk.V e_LZip 71155 Si Lic#1146 Phone(925)3-5/673 <br />City 36 PyclAkcx Licit Phone# 4gso <br />GIS Coordinates: X , Y , Township Range Section <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> Parcel# _219- <br />Zip phonet02c) lt 7 -O g7 7 <br />C-57 Contractor C,Ye DO In Address 7So goiAx_Rd. <br />Consultant / Sub Cntr CrifrOt ICL Ehtoqr-CIViid Address Co. evy -251 <br />WORK TO BE PERFORMED: <br />'AI NEW WELL! BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />a SOIL BORING # <br />)D,WELL # tki (tikci MU- s <br />fl Other <br />COMMENTS: <br />TYPE OF WELL <br />MONITORING <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />-43 HOLLOW STEM DIA. OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 7(` <br />D AIR HAMMER/DRIVEN CASING THICKNESS9':iVa 40 TYPE OF CASING: a STEEL irPvc D OTHER: <br />a MUD ROTARY DEPTH OF GROUT SEAL p-tot TREMIE TYPE TO BE USED: --BAUGERS B'HOSE <br />D PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes ,.No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />a HAND AUGER 'GROUT SPECIFICATIONS Pc”Ale..Art. T.& - <br />(1 OTHER APPROX. BORING DEPTH_/`' 3C1 A-BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED th,i, 0 (if YES, list specifications in comment section) <br />a EXTRACTION <br />a VAPOR <br />a AIR SPARGE/ OZONE <br />a SOIL BORING <br />a OTHER: <br /> <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x C <br />Print Name CH e_t s <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: / C O W.Yo c.o./hie_ 7fl44 ) C/51- <br />WORK PLAN DATED: F&ruis r j / 0 .2(V2 3 <br />Application Accepted By y 71.4, r4")2 Date Issued <br />Grout Inspection By "Otr-.",:tetr Date .57 rii/ 64 Final Inspection B <br />Destruction Inspection By Date <br />Area <br />Date 572S1 y <br />COMMENTS /CONDITIONS. .1 YLS i4 ii ±I in-, 0 + q r 0 Li raLded•e-r-Wi try; Lz) 11,5 M W 4 <br />ACCOUNTING ONLY: AID# FAC# - <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE-4. INVOICE <br />iP 6'9 • o o 1 9 00 SR# 6 6 3 ri 7 g 2 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign perm Encroachment doc 9/30/02 _ <br /> <br />U DESTRUCTION (choose type below) <br />13 OVER-BORE. DIAMETER <br />a PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />Title/Company V <br />Date <br />U-.0..DLN- <br />11.1S1b3