Laserfiche WebLink
San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />ORIGINAL <br />SITE <br />MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />�rF0R� II .� 3>,;Ll II 4 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DA SIS$ �1) 1- O c j <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 <br />Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />/ry�wj o� ��� Assessors <br />WELL Location lig fly D�L✓�" i� Cross Street sWAO lall ',' city Zipg�Parcel# <br />PROPERTY / ` �9 8 —✓J f <br />Owner Tr ®f li>jj�j`i�00 Address_ G✓GfJJ�1i •City42M�W ZiPf�-;Phone#_ Z <br />C-57 Contractor 141011w+4r[yL�L�I�Address 5-2 1244City 124 UIS1 ZipiJ�%LLic# DO%Phone# 7G7— �% �/.�Od <br />Consultant /Sub C n t r JW ress W%L K1J City efe dW-✓'A Lic# Phone# `1✓6 �6f �YaO <br />GIS Coordinates: X <br />Y <br />Township <br />Ra <br />Section <br />WORK TO BE PERFORMED -:- <br />I] NEW WELL / BORI (CPT, GEOPROBE, HY ROPUNCH, HAND -AUGER, OTHER') []DESTRUCTION (choose type below) <br />OVER -BORE. DIAMETER <br />[] WELL # [] PRESSURE GROUT <br />[] "Other GROUT SPECIFICATIONS <br />COMMENTS: 1 ; W/� � Tb 42!aGlic/f%/,�T�/� <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[] MONITORING [] HOLLOW STEM DIA. OF BOREHOLE [] MULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA: <br />[] EXTRACTION [] AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: [] STEEL [] PVC [] OTHER: <br />[] VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL /S Z TREMIE TYPE TO BE USED: [] AUGERS [] HOSE <br />[] AIR SPARGE/ OZONE []'PUSH POINT (GP or CPT)GROUT SEAL PUMPED: [a,Yes a No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />[],SOIL BORING [] HAND AUGER GROUT SPECIFICATIONS s��/IT G�h9G�T <br />[] OTHER: [] OTHER APPROX. BORING DEPTH [I BOLTED TRAFFIC BOX or [] 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x <br />Title/Company Gv✓T / 9— <br />��1�✓ <br />Print Name CG//�� /�'�"�'` <br />.� -I,, <br />S <br />Date <br />/� <br />INVOICE <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: �b �70 <br />/� <br />��1� <br />�0 <br />WORK PLAN DATED: <br />0 '1 S -0-312 <br />Application Accepted By <br />Date Issued <br />Q <br />7 �" <br />Area <br />Grout Inspection By <br />Date Final Inspection By <br />Date -119 <br />Destruction Inspection By <br />Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE EST # <br />INVOICE <br />350 <br />Zy 3g <br />7 • Z. SR#Z -� 1 <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Enc ettt�d�o —'- <br />EHD 29-02-001 <br />9/30/2003 <br />