Laserfiche WebLink
�iVEL . ERMIT APPLICATION F�. .'ISI SITE <br /> �TF� ,-� �, ; `"' MITIGATION <br /> � ��} �� E) SAN JOAQUIN.000NTY:. UNIT IV <br /> ENVIRONMENTAL. HEALTH DEPARTMENT (EHD) <br /> JUL 1. 4 2003 304 E. Weber, Third Floor, Stockton;° CA., 95202 <br /> +=WRC NIENT HEALTH (209).468-3449 <br /> PERNIIT/JERVII ES AVON-REFUNDABLE PERMIT'EXPIRES 7 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in compliance with San . <br /> Joaquin County Development Title,Chapter <br /> 9-1115.3 and the Standards of San Joaquin County Environmental Health Department Assessor's <br /> `� <br /> WELL Location`t2 3 pyt/ frvrCG• Cross Street frurlt�! c;t}IS7�rc � ! . zip L� -Parcel# � 7 2 30 ® <br /> te- 3�r Af• ,�L MoD a G� c{ <br /> PROPERTY Owner 9 1fL�4ri� FLfm , L• Address s�{�" U Clty cQ�G air/ Zsp 9 L Phone# r7 d <br /> I �p�rLL D ' <br /> C-57 Contras nrxJ¢ST Z Address373 3 /r� city. zip <br /> Phon �� ��"7� <br /> f ��7 S �7 ci �1a-+! uc#�LZ— PhPn 9 72C <br /> Consultant/Sub Cnir _Crag -Address <br /> GIS Coordinates:X Y Township Range Semon <br /> RiC TO BE PERFORMED: <br /> EVV WELL/BORING(CPT,GEOPROBE,HYDROPUNCH;HAND-AUGER,OTHERS DESTRUCTION(choose type below) <br /> ©SOIL BORING# 1]OVER-BORE <br /> ©WELL# (j PRESSURE GROUT <br /> ,mer Grout Specifications: . <br /> COMMENTS <br /> TY E OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r r <br /> MONITORING OLLOW STEM DIA.OF ��BOREHOLE MULTIPLE CASINGS? MULTI-LEVEL?0 WELL CASING D[A: <br /> 0 EXTRACTION AIR HAMMER/DRIVEN, CASING THICKNESS Ij `D! TYPE OF CASING: 11 STEEL e)PVC a OTHER: <br /> (�VAPOR MUD ROTARY DEPTH OF GROUT SEAL T r TREMIE TYPE_TO BE USED: UGERS l7 HOSE <br /> PUMPED` Yes No (NOTE: M.AXIMU REE-FALL DEPTH 1S 30' <br /> 11 <br /> AIR SPARGE!OZDtIE �PUSH POINT GROUT SEAL PU � (] l <br /> jl SOIL BORING [l HAND AUGER GROUT SPECIFI6•116NS: a2 o 70'� <br /> OTHER:_ 11 OTHER APPROX.BORING"DEPTH 4kBOLTED fRAFFIC 13OX or 11 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications herey <br /> *COMMENTS: Atio. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS_ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County din es, ules and Regulations, and all applicable California <br /> State Laws. <br /> Signed /1 _ Title/Company <br /> E Print Name AU L ���r Date <br /> DEPARTMENT-.USE ONLY <br /> i <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: Dat <br /> f <br /> Application Accepted By. e Issued a <br /> Grout inspection By Date Final Inspection By Date 2 <br /> Destruction Inspection By Date <br />{ COMMENTS/CONDITIONS: <br /> ACGOUN—nNG ONLY: AID# <br /> i <br /> i PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D Y DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> jk <br /> C-57 WC -WAIVER C-57 Letter of•Auth r+ atio o sign permit Encroachment dos 8/29/02 <br /> E E: <br />