Laserfiche WebLink
San Joaquin County <br />Environmental Health Departmen A L SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95g,92, MITIGATION fuj <br />d (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgcx.orgieh 1 2005 UNIT Iv <br />tr4\coNmENT HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATEfTWUrEtT,'SERVICES <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 Dev.Amstit, Chapter.9-1115.3 4nd the Standards of San Joaquin County Environmental Health Department. <br />hVI StO n U/50/067 <br />WELL Location 72-1 3-1 e- St Cross Street O. r'Ner4- St City S410c-N6Y1 Zip c/C2-07- Parcel# -- \ <br />L PROPERTY Di95i'et- otna Wad) LLC- .ttl-e- 1 <br />Owner <br />C-57 ContractorGrli ces+'- Address 4-011Je. Rd- cityPhr+illel zp 914553 Lot Phone# ("t 7--S) 3 1 3 - 58Do <br />Consultant / Sub Cntr akria Giiirellgkett}ctiAddress 2 Pe-YAC-ItA.S Si City SigyltiWlet Lic# Phone# (1-01-) 93S- (OM <br />GIS Coordinates: X <br /> <br />, Y Township Range Section <br /> <br />Assessors <br />c/o Scot+ I'. Darnon Address 21-6-+ E Freworo- S+.1 City SA-ock+crY1 Zip 15-245-- phone# (20 (1) 4 cs , <br />c, yg c;145- <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />I] SOIL BORING # <br />H.WELL # `-.5- <br />1:1 *Other <br />COMMENTS: R.-\\ <br />DESTRUCTION (choose type below) <br />0 OVER-BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />MONITORI NG <br />0 EXTRACTION <br />fl VAPOR <br />fl AIR SPARGE/ OZONE <br />i] SOIL BORING <br />0 OTHER: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />iffHOLLOW STEM DIA. OF BOREHOLE 1:1 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 AIR HAMMER/DRIVEN CASING THICKNESS5C k 4 b TYPE OF CASING: 0 STEEL #PVC 0 OTHER: <br />0 MUD ROTARY DEPTH OF GROUT SEAL '---β€˜ (L. TREMIE TYPE TO BE USED: l] AUGERS 14-10SE <br />p PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Kes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />I] HAND AUGER GROUT SPECIFICATIONS Le vt....1,,,_A- V) tA-t- <br />1.-BOLTED TRAFFIC BOX or 0 STOVE PIPE 0 OTHER APPROX. BORING DEPTH (:: C '- <br />CONDUCTOR CASING PROPOSED )013 (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 Ordina e β€ž1, . lations, and all applicable California State Laws. <br />el' Agri/ <br />61/1 Date <br />#β€”} <br />WORK PLAN DATED: <br />Application Accepted By <br /> Date Issued <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS! CONDITIONS. <br />ACCOUNTING ONLY: AID# FAC# <br />I <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST INVOICE <br />'-0 f /I/6U/ '-1 26/ki adt ooww / <br />C-57 V WC V -WAIVER C-57 Letter of Authorization to sign permit "i4Encr,9chthent doc <br />d-r-020-4x-reβ€˜--""V 64" END 29-02-001 <br />9/30/2003 <br /> <br />Signed x <br />Print Name <br />SITE MAP MAP IN UNIT IV FILE, ADDRESS: <br />DEPARTMENT USE ONLY <br />c 2f ?/ <br />Title/Company 0 0002.r - areal- 641P/4 <br />- o 5 Area 66 <br />Date Final Inspection By <br />Date <br />Date