Laserfiche WebLink
FILE CCPD` <br /> ,off -"• ra .man Joaquin Co-inty <br /> Environmental Health.Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> W. (209)468-3449 Fax: (209)468-3433 Web:www.co,san-joaquin.ca.us/ehd UNIT IV <br /> �.r✓OR <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 /> G Assessors ,I <br /> WELL Location ( ross Street NnuJV –city S� Zip ! �� Parcel# <br /> PROPERTY t <br /> Orme ", Address Y. F3CY\ i !of 1 City (. Zip�Phone# L-Rol �J 3?51 <br /> C-57 Contractor Address � City ro <br /> / ic#6 ar Phone# 3 -35-- <br /> Consultant/Sub Cntr_ftfQ Address City_jakAMLic# &i30 a 4 7 Phone# a <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED:. <br /> p NEW WELL 1 BORING (CPT,GEOPROBE,HY ROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> SOIL BORING# a OVER-BORE. DIAMETER <br /> WELL# p PRESSURE GROUT <br /> 0,•Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS A y <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE-2 p MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA:_p _ <br /> a EXTRACTION ©AIR HAMMERIDRIVEN CASING THICKNESS Y�f TYPE OF CASING: 0 STEEL A VC Q OTHER; <br /> ©VAPOR a MUD ROTARY DEPTH OF GROUT SEAL­t.Z,r TREMIE TYPE TO BE USED: 0 AUGERS d HOSE <br /> a AIR SPARGE!OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED; a Yes ,KNo (NOTE: MAXIMUM�y–FREE-FALL DEPTH IS 30') <br /> U SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS �1C"�`�Q�+D� '�► it -- <br /> a OTHER: . p OTHER APPROX.BORING DEPTH 990TED RAFFIC BOX or d STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> + l <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, d all applicable California State aws. <br /> I <br /> Signed x TitlelCompany <br /> Print Name I O1f1Y� Date <br /> DEPARTMENT USE ONLY <br /> f M <br /> SITE MAP IN UNIT IV FILE,ADDRSS: rP <br /> WORK PLAN DATED' 0'0 r7 <br /> Application Accepted By Date Issued 26 Areae <br /> Grout Inspection By Date Final Inspection By _ e <br /> I. <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> AC <br /> COUNTING ONLY: AID# FAC# <br /> S FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE � <br /> 7sR#C-5 � WC—WAIVER_ C-57 Letter of Authorization to sign permit Encroachment do <br /> EHD 29-02-001 <br /> 9/30/2002 <br />