Laserfiche WebLink
i T � COQ' <br /> '� �o San Joaquin County <br /> Environmental Health Department SITE <br /> "i 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209) 468-3449 Fax: (209)468-3433 Web:WWW.sjgov.org/ehd UNIT IV <br /> ell Permit Application <br /> NON-REFUN ABLE PERMIT EXPIRES t 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 8-111 .3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location \a 5 W Cross Street S. ct, 1 city S� Assessors <br /> oc��G4or, Zip g5Lo6 Parcel# �b 3 -Z3o. -1 <br /> PROPERTY <br /> Owner GAw Address S4 City t\`n� Zlp SSS Phone# 2.4 of S <br /> C-67 Contractor \f.w Ot1.>\\.a", Ada ss p'O % 4 y\\o City ZS 01, Zip)SV )acct Phone# \yP '11l -µl3o <br /> Consultant Setr6ntr Ga.a\c `r Address It City�ll�r�( J Lic# Phone#5 }'�-��\� <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> O NEW WELL/BORING (CPT,GEOPRO g HY ROPUNCH,HAND-AUGER,OTHER*) 0 DES CTION oose type below) <br /> SOIL BORING# 3 /�'- <br /> 0WELL# K'/%p �OVER-B METER <br /> O'Other /Uo L4fg aPRESSUR OUT <br /> COMMENTS: .tomq ,� S �A GROUTS CIFI IONS <br /> t W o r p q - C <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING I HOLLOW STEM DIA.OF BOREHOLE Q 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERfDRIVEI I CASING THICKNESS v TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> a AIR SPARGE/OZONE 0 PUSH POINT(GP or C PT)GROUT SEAL PUMPED: n Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 11 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (If YES,list specifications in comment section) <br /> COMMENTS: O C\Lp <br /> NOTE: OFFSITE BORINGS R QUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKI IG HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I It �ypre ared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina ce , Rul an lotcins, and all applicable California State Laws. (\ <br /> Signed x____ T M:7 Title/Company <br /> Print Namewo l�C Jo V�J Al 1'CT' Date (o I 13 O b <br /> DEPARTMENT USE ONLY , �1n <br /> SITE MAP IN UNIT IV FILE, ADDRESS: RLlvrvt <br /> WORK PLAN DATED: S -7-0 <br /> 5 <br /> -7—OS <br /> Application Accepted By Date Issued Z�OT & Area <br /> Grout Inspection By Date Final Inspection By pate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> [PE FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �j rel t?A —vi oo SR Q(� <br /> C-57,/— WC__-WAIVER! C-'07- etter of Authorization to sign permit_Encroachment doc <br /> ERD 29-02-001 <br /> 6/22/04 <br />