Laserfiche WebLink
09/26/2005 14: 28 2094683433 EHD <br /> J .: PAGE 02 , <br /> San Joaquin County, <br /> roke Lit lea.lth Department <br /> TE <br /> 304 East Weber A�Venue, 3rd Floor, Stockton„CA.95202 �,A <br /> • MITIGATION <br /> (2o9)463-3449 Fax: (249)468-3433 Web: <br /> �• !�8 UNIT IV <br /> _ Well PennitApplicatiigiR jc),10 llP,l coLl TY <br /> NON-REFUNDAIBLE PERMIT EDWIM I yEAR I ��T A 1 <br /> APPllcation is hereby made to San Joaqutrz County for a permit 10THENT <br /> CortSLvuX a+idlor install the work described. This application is made in <br /> Joaquin County Deve��ro11pment'Td e,Chap[Ieer 9-1115.3 and the Standards/of San Joaquin County Fsricunmerdal health DeparhneM. �w�enoe with San <br /> WELL Locartlon 'l "1 ross Street�w►�C 5cityp��,,/ Pssessas <br /> 4f <br /> PROPS , <br /> Owner s ress1Oy X40 A <br /> C-67Corrtr`dCtor •�i Address - '.titPal �� <br /> City tJ <br /> �iD 's Ny f UCUC* Phone# 3'�q 3bC <br /> F ConsultOlUt I sub Cntr_Q-L$ Address Zt 1C.,a aj, -$ LIC# <br /> �11��� <br /> GIS Caotdinates;X Y Township Range.Section <br /> y WORK TO BE PERFORMED: <br /> i `JEW WELL I BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER.OTHER") <br /> ` n SOIL BORING tESTRUCTION (choose type bel" <br /> ZJE S D-;4OVER-BORF- DIAMETER JC> re <br /> Q`Other U PRESSURE GROUT "— <br /> COMMENTS: Matt 4 rwt GROUT SPECIFICATIONS <br /> i ypg QF VIML! 1NS7ALLA1 FONt PE <br /> tVSTRUCTiON 5PP-CIFI0ATi0I+IS <br /> 1ONITORING Il HOLLOW STEM DIA.OF BORE=HOLE/fl 1 <br /> Y�CTRACTION II AIR HAMMER1pRIVl=N CASING THICKNESS �OLjIPL1=C�'SING$ [j MULTI-LErV(w1. yVEL L CASING DIA: <br /> Q VAPOR -- T'PE O1=CASING: G STEEL>NI VG D OTHER: <br /> Q MUD ROTARY DEPTH OF GROUT SEAS f►- TREMIE TYPE TO BE USED: <br /> �IR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Y� DLL ERS ©HOSE <br /> p SOIL BORING Q HAND AVUQ No (NOTE: MAXIMUM FREE-FALL DEPTH 1S 3t?'} <br /> GROUT SPECIFICATIONS <br /> 0 OTItER:_.. n 0TH APPROX_BORING DEPII{ 1Jo%-, 10 a BOLTED TRAFFIC BOX or 11 STOVE PIPE <br /> CflMN1EHT5• � +�- <br /> GONDU R CASINGPROED�ED (d YES,list spedNcattons in comment section) <br /> Fa &Q&LK�t <br /> NATE:FOFFSiYE gORJNGg 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 Wolf will be done In accordance with San Joaquin <br /> y CountiOrdinan es, nd R I ons,and all applicable California State LAWS, <br /> Signed . <br /> 71tte/Company 0 � EGEI � <br /> Print Name r - <br /> Q s 9. X045 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N I1.E, ORE 58; I �Op uiN p1 <br /> WORK PLAN DATED: <br /> 1 z.aa � <br /> Applieatien Accep%d By <br /> Grout kwpadion Date Is Zb p Area zt <br /> Date_ --�-- <br /> ('- Daslrurction Ir Paation Date F Inspecterm By_ Date <br /> COMMENTS I CONDITIONS: <br /> ACCovNTINrG ONLY: AID# <br /> FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK if <br /> RECD BY DATE PERIVQT I SF;RYICE REQUEST# INVOICE <br /> F3. G D, o c7 a4a-k 2.-� 4(��.�os $R# gLloZy <br /> SU 2 WC -WAIVEk 29-02-001 C-57Letter of Authorization to sign permit_Encroachment doq <br /> wzzroa <br />